surgical anatomy of salivary glands

1. Presented by Guided by
SURGICAL ANATOMY OF SALIVARY
GLANDS
Presented by-
Dr. Maroti Wadewale
II year
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY, GDCH,
Guided by-
Dr. Prajwalit Kende (HOD & Prof.)
Dr. Jayant Landge (Asso. Prof.)

2. INTRODUCTION
SALIVARY
GLANDS
Major-6
(Paired)
1. Parotid
2. Submandibular
3. Sublingual
Minor-600
Tongue
Palate
Lips
Cheeks

3. According to
there secretions
Serous
Parotid Von Ebner
Mucous
Sublingual Labial & Buccal
Blandin nuhn
(ant lingual)
Mixed
Predominantly
serous
-submandibular
Predominantly
mucous
1. Sublingual
2. Post portion of
ant lingual gland

4. EPITH OUTGROWTH
CANALIZATION
DEVELOPMENT
Patel VN, Hoffman MP. Salivary gland development: a template for regeneration. InSeminars in cell &developmental biology 2014 Jan 1 (Vol. 25, pp. 52-60). Academic Press.

5. FUNCTIONS OF SALIVA
 Other functions- Excretory functions, Water balance, Hormonal function.
Mandel ID. The functions of saliva. Journal of dental research. 1987 Feb;66(1_suppl):623-7.
Lubrication of
food
Speech
Moistening of
buccal mucosa
Medium for
perception of
taste
Debridement!l
avage.
Protective
function
Maintenance
of ecological
balance.
Soft tissue
repair.
Maintance of
mucous
membrane
integrity
Digestive
enzymes

6. PAROTID
GLAND

7. PARA OTIC
AROUND EAR
PAROTID GLAND

8. -Largest
- Wt- 25 gm (15-30 gms)
Irregular, lobulated, yellowish mass
Neoplasm commonly
involves superficial lobe
When both lobes
involved – classical
dumbbell shaped
swelling
McWhorter, G. L. : Relations of Superficial and Deep Lobes of Parotid Gland to Ducts and to Facial Nerve, Anat. Rec. 12:149-154 (Feb.) 1917.

10. DEVELOPMENT
• Ectodermal in origin.
• The parotid primordium grows during the 6th week of intrauterine life as a
cord of cells by proliferation of ectodermal lining of the vestibule of the mouth
near the angle of archaic oral fissure.
• It grows backwards in the direction of the ear and branches repeatedly. The
parotid bud and its branches canalize to create the duct system and acini.
Ectodermal myoepithelial origin
6th gestational week – development begins
10th gestational week – arborization and canalization begins
18th gestational week – early secretions
28th gestational week – the maturation of the acini and
ducts

11. EXTENT OF GLAND Superioorly
Anteriorly
Inferiorly
Posteriorly
Spratt JD, Abrahams PH, Boon JM, Hutchings RT (2008). McMinn's Clinical Atlas of Human Anatomy (6th ed.). St. Louis, Mo.: Elsevier/Mosby. p. 54. ISBN 978-0-8089-2318-3.

13. PAROTID CAPSULE
False
capsule
True
Capsule
Conley, JJ. Surgical anatomy relative to the parotid gland. In: Conley, JJ, ed. Salivary Glands and the Facial Nerve. Stuttgart, Germany: Georg Thieme Verlag; 1975: 7–13

14. SIGNIFICANCE OF CAPSULE
Donovan DT, Conley JJ. Capsular significance in parotid tumor surgery: reality and myths of lateral lobectomy. The Laryngoscope. 1984 Mar;94(3):324-9.
As parotid
fascia is
unyielding
and tough,
immense
pressure
builds up
Surgica
l
significa
nce
Early
incision
&
drainage
is t/t of
choice.

15. EXTENSION OF GLAND
Glenoid
process
Facial
process
Pterygoid
process
Accessory part
of gland
Cervical
lobe
Russel RCG, Williams NS, Bulstrode CJK. Bailey and Love's Short practice of surgery, Oxford University Press, New York. 2004;24≈

16. RELATIONS OF PAROTID GLAND

17. SUPERIOR RELATIONS
 Superior Surface - Concave
Related to –
Cartilaginous part of external acoustic
meatus
Post. Aspect of temperomandibular joint
Auriculotemporal Nerve
Superficial Temporal vessels
Apex - Overlaps posterior belly of digastric and
adjoining part of carotid triangle

18. SUPERFICIAL RELATIONS

19. MEDIAL RELATIONS

20. BORDERS

21. STRUCTURES WITHIN THE GLAND
3 chief structures either in part or in whole traverse the gland and branch inside it. From superficial to
deep these are:
•Facial nerve.
•Retromandibular vein.
•External carotid artery.
Medial to lateral
External carotid A., retromandibular vein & facial nerve

22. ARTERIAL ANATOMY
• The external carotid artery pierces the lower part of the posteromedial surface to
goes into the gland where it inhabits the deep zone of the gland. Inside the gland it
breaks up into superficial temporal and maxillary arteries. The transverse facial
artery, branch of superficial temporal artery issues via the anterior border of the
gland

23. VENOUS ANATOMY
• The retromandibular vein takes up the intermediate zone of the
gland and is composed by the unification of the superficial
temporal and maxillary veins. It finishes below by splitting into
anterior and posterior sections. The anterior section joins the facial
vein to create the common facial vein while posterior section joins
the posterior auricular vein to create the external jugular vein.

24. NEURAL ANATOMY
Great Auricular Nerve
• Enters the tail of the parotid gland, it divides into
anterior and posterior branches.
• Anatomical dissection and histological examination
of the anterior branch of the great auricular nerve
revealed that in most parotid glands(57%)
• Specific care must be taken during the elevation of
the lobule not to sever the distal branches of the
nerve as they enter the lobule.
Zohar Y, Siegal A, Siegal G, Halpern M, Levy B, Gal R. The great auricular nerve; does it penetrate the parotid gland? An anatomical and microscopical study. Journal of Cranio-
Maxillofacial Surgery. 2002 Oct 1;30(5):318-21.

25. FACIAL NERVE & PAROTID
The facial nerve has five segments before exiting the
temporal bone:
• Intracranial (pontine) segment (23 to 24 mm long
and extends from the pons up to the internal
auditory canal)
• Internal auditory canal (meatal) segment (7 to 8
mm and is contained within the internal auditory
canal)
• Labyrinthine segment (3 to 4 mm long and extends
from the fundus of the internal auditory canal to
the geniculate ganglion)
• Tympanic segment (12 to 13 mm long and extends
from the geniculate ganglion to the pyramidal turn)
• Mastoid segment (15 to 20 mm long and extends
from the pyramidal turn to the stylomastoid
foramen

26. The facial nerve is most superficial.
It enters the gland via the upper part of the posteromedial surface and breaks up
into its terminal branches inside the gland.
Before the main trunk of the facial nerve enters the parotid gland, it usually gives off
branches to the posterior belly of the digastric muscle, the stylohyoid muscle, and the
auricular muscles.
As the facial nerve enters the parotid gland, it forms the pes anserinus (the
characteristic multiple branching pattern that resembles a goose foot)
Pather N, Osman M. Landmarks of the facial nerve: implications for parotidectomy. Surgical and Radiologic Anatomy. 2006 May 1;28(2):170-5.

27. PATTERN & BRANCHING- DAVIS ET AL
Davis, RA Anson, BJ Budinger, JM Kurth, LR. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol Obstet 1956;
102 (4): 385–412
Type I absence of anastomoses between the two
main divisions, temporo-facial and cervico-facial
of the facial nerve.
Type II anastomoses only within the temporo-
facial division of the facial nerve.
Type III displays one single anastomosis between
the main divisions.
Type IV two anastomotic loops between the
temporal and zygomatic branches, as well as
connections between the zygomatic and buccal
rami;
Type V two loops in the cervicofacial division
intervened with branches of the temporo-facial
main branch.
Type VI very extensive intermixture of facial
nerve branches.

29. IDENTIFICATION OF FACIAL NERVE
Numerous soft tissue and bony landmarks have been
proposed to assist the surgeon in the early identification
of this nerve.
Can be identified by
Antegrade approach- Early identification of nerve
trunk where it exists from stylomastoid foramen
Retrograde approach either from mandibular br. or
peripheral branches alongside parotid duct
Supravital staining of parotid gland,
blue colour  gland
gleaming white  facial nerve
unstained  tumour
Pather N, Osman M. Landmarks of the facial nerve: implications for parotidectomy. Surgical and Radiologic Anatomy. 2006 May 1;28(2):170-5.

30. Locating the main trunk of the facial nerve
4 constatnt
landmarks
Styloid process
Tragal pointerThe mean closest distances from the
tympanomastoid suture and posterior belly
of the digastric muscle to the facial nerve
are 1.8 mm (range 0–4 mm) and 12.4 mm
(range 7–17 mm), respectively.
Should the main trunk not be identifiable
at the stylomastoid foramen, alternative
means of identification can be undertaken.
One approach is to locate the distal
branches and trace them centrally toward
the main trunk.
Posterior auricular artery bleeds frequently
while looking for nerve in this region
1. Witt, R Weinstein, G Rejto, L. Tympanomastoid suture and digastric in cadaver and live parotidectomy. Laryngoscope 2005; 115 (4): 574–577
2. Pather N, Osman M. Landmarks of the facial nerve: implications for parotidectomy. Surg Radiol Anat. 2006;28(2):170–175.

31. Saha S, Pal S, Sengupta M, Chowdhury K, Saha VP, Mondal L. Identification of facial nerve during parotidectomy: a combined anatomical & surgical study. Indian Journal of
Otolaryngology and Head & Neck Surgery. 2014 Jan 1;66(1):63-8.

35. A first line was marked with the ink starting from the tip of the mastoid
process, running along the superior border of the PBD.
second line was drawn along the posterior border of the ramus. two lines
intersect with each other anteriorly, forming the apex of the triangle (angle a)
third line starting from the tip of the mastoid process, (angle b) running
anteriorly, till it joins the second drawn line along the posterior border of the
ramus (angle c).

36. BY RETROGRADE
 Retromandibular vein
Proximity of marginal mandibular branch to retromandibular vein
at its point of emergence at the tail of gland
Facial nerve lies superficial to the vein
By working backwards along the nerve , the 2 divisions, other
branches & main trunk can be found
Kopuz C, Ilgi S, Yavuz S, Onderoglu S. Morphology of the retromandibular vein in relation to the facial nerve in the parotid gland. Acta Anat (Basel). 1995;152:66–68.

37. Facial nerve can be located finding the buccal
branch which runs parallel to zygomatic arch 
1cm below it
It runs parallel & inferior to parotid duct.

40. • Farrior et al. Noted in children facial nerve is
located through triangle formed by cartilaginous
ear canal, sternocleidomastoid muscle and
posterior belly of diagastric muscle.
• In elderly or obese pts. Facial branches are
tortuous both mediolaterally & anteroposteriorly
• They shuld be constantly stretched while the
nerve being dissected, otherwise liable to
damage
Farrior JB, Santini H, Facial nerve identification in children. Otolaryngol Head Neck Surg. 1985 Apr;93(2):173-6.

43. PAROTID DUCT
• Ductus parotideus; Stensen’s duct (named after the
Danish anatomist Niels Stensen (1638-1686)
• originates in the posteroinferior part of the gland.
• 5 cm in length; 3mm in dia., 1.2mm at isthumus
(buccinator), 0.5mm at orifice in oral cavity
1. . Clarke E. Nicolas Stensen and the Brain [Abstract]. (1965) Proceedings of the Royal Society of Medicine. 58 (10): 749.
2. Zenk J, Hosemann WG, Iro H. Diameters of the main excretory ducts of the adult human submandibular and parotid gland: a histologic study. (1998) Oral surgery, oral
medicine, oral pathology, oral radiology, and endodontics. 85 (5): 576-80.

44. Passes forward across masseter; finger breadth
downward zygomatic arch
Surface anatomy of Parotid Duct  Corresponds to
middle third of a line drawn from lower border of
tragus to a point midway b/w nasal ala and
upperlabial margin
OPPENHEIM, H., & WING, M. (1960). Sialography and Surface Anatomy of the Parotid Duct. Archives of Otolaryngology - Head and Neck Surgery, 71(1), 80–83.

45. • Crosses masseter – junction of upper & middle 1/3rd
• At anterior border of masseter, --turns medially to traverse buccal pad of fat(corpus
adiposum) & buccinator
• Then, runs obliquely forwards between buccinators & buccal mucosa to open
against upper 2nd molar
• This oblique run act as valve like mechanism, preventing inflation of duct system
during violent blowing in mouth
• While crossing masseter, receives the accessory parotid duct
1
3
2

46. RELATIONS OF PAROTID DUCT
Parotid duct lies inferior to
1. Acessory gland
2. Transverse facial artery
3. Upper buccal branches of facial nerve
Parotid duct lies superior to
1. Lower buccal branch of facial n.

47. ACCESSORY PAROTID GLAND
• normal variant and represent ectopic salivary tissue separate from, but usually in close
proximity to, the main parotid glands.
• on average, within 6 mm of the main parotid gland
• Accessory parotid glands have their own blood supply and secondary duct emptying into
the main parotid duct
Dongbin Ahn, Chang Ki Yeo, Soon Yong Han, Jeong Kyu Kim. The accessory parotid gland and facial process of the parotid gland on computed tomography. (2017) PLOS ONE.
12 (9): e0184633.

48. Failure to identify and remove the accessory parotid during parotidectomy could be
one of the cause for tumor recurrence.
Frequency of malignancy is reported to be more in accessory parotid gland than
main parotid gland
Toh H, Kodama J, Fukuda J, Rittman B, Mackenzie I. Incidence and histology of human accessory parotid glands. The Anatomical Record. 1993 Jul;236(3):586-90.

49. BLOOD SUPPLY AND LYMPHATIC
DRAINAGE
• External carotid artery & its branches supply
the gland
• Retromandibular vein drains the gland
• Lymph vessels drain into parotid lymph nodes
& the cervical lymph nodes
Superficial
Deep
Garatea-Crelgo J, Gay-Escoda C, Bermejo B, Buenechea-Imaz R. Morphological study of the parotid lymph nodes. Journal of Cranio-Maxillofacial Surgery. 1993 Jul 1;21(5):207-
9.

50. NERVE SUPPLY
• SYMPATHETIC- from the superior
cervical ganglion via the external
carotid plexus. Injury to the
cervical sympathetic chain leads to
anhydrosis as part of Horner’s
syndrome.
• SENSORY-
Auriculotemporal nerve- Frey’s
syndrome
Great auricular nerve (C2 and C3).
The C2 fibres are sensory to the
parotid fascia.

51. PARASYMPATHETIC
Segal K, Lisnyansky I, Nageris B, Feinmesser R. Parasympathetic innervation of the salivary glands. Operative Techniques in Otolaryngology-Head and Neck Surgery. 1996 Dec
1;7(4):333-8.

52. The parotid gland is palpated mainly externally but also bimanually around the anterior border of the
ramus of the mandible
CLINICAL EXAMINATION

53. SURGICAL APPROACHES TO PAROTID
GLAND
• Ideal incision  good exposure with best esthetic
results
Gutierrez  laid down guidelines for gaining
access to parotid gland in 1903
• Incision has  temporal extension
• Preauricular component
• a limb extending to neck in one of
skin crease
• Drawback – is the esthetics in case of development
of keloid

54. • Redon and vaillant and laudenbach suggested
modification to Gutierrez’s incision
•  they did not consider the temporal incision
line for exposure of parotid gland

55. • Adson and ott described  ‘Y’ shaped incision with
preauricular sector , postauricular sector and
cervical incision line
• Advantage – improved esthetics
• Disadvantage – impairs dissection
Incision is located in carotid region
Samengo (1961)  similar incision having
preauricular, a postauricular and a neck extension

56. • Appiani, in 1967,  technique that involves
an incision within lower portion of scalp
• Advantage– better esthetics as incision is
masked by hair
• Disadvantage – temporal extension is short
and this impairs access to anterior portion of
gland

57. • Standard incision is modified Blair’s incision
• Skin incision  preauricular crease 
extends superiorly to level of root of helix 
extends inferiorly around lobule of ear over
the mastoid tip  curves down along the
sternocleidomastoid muscle

58. COMPLICATIONS OF PAROTID SURGERY
Treatment of complications of parotid gland surgery. Marchese-Ragona R, De Filippis C, Marioni G, Staffieri A Acta Otorhinolaryngol Ital. 2005 Jun; 25(3):174-8.

59. Temporary  more common (10 – 50 % of parotidectomies)
Seen in large tumors, deep lobe involvement, malignant cases
• Lower division branches  commonly involved (marginal mandibular)
• Resolves in few weeks or months especially in elder pts.
 Permanent  0-5 %
• Due to transection of nerve / cautery injury
1. O’Brien CJ. Current management of benign parotid tumors: role of limited superficial parotidectomy. Head and neck 2003;25:946-52
2. Guntinas-Lichius O, Kick C, Klussmann JP, Jungehuelsing M, Stennert E. Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by
lateral or total parotidectomy. European Archives Otorhinolaryngol. 2004 Mar;261(3):143-6. Epub 2003 Jul 22.

60. SEROMA/ SALIVOMA/ SALIVARY FISTULA
• Leakage of serous fluid and saliva from transected parotid
tissue is an expected complication  few days
• Drain should be placed for 2- 3 days
• After drain removal  collection present  aspirated
• Pressure dressing may be useful to speed resolution

61. FREY’S SYNDROME
Gustatory sweating  sweating on side of face while eating
• d/t transection of cholinergic secretomotor fibres of parotid
gland
• Subsequently  sprout new axons  innervates to sweat
glands in skin flap, which are also responsive to
acetlycholine
10% of parotidectomy will complain of gustatory sweating, on
questioning
While it can be demonstrated objectively in 95% of pts.
 develops within weeks or months, may be delayed for
several years

62. EAR NUMBNESS
Expected outcome after parotid surgery
d/t transection of greater auricular nerve
Area of numbness diminishes over several months,
but pt. are left with persistent numbness over ear
lobe

64. INTRODUCTION
• Irregular in shape ; about size of walnut
• Mixed ; predominantly serous
• weighing 7 to 16 g, is located in a triangle of the
neck bordered superiorly by the inferior edge of
the mandible and inferiorly by the anterior and
posterior bellies of the digastric muscle.
• Appears ovoid in shaped laterally;
but U shaped  sagitally
• 2 lobes  large superficial & small deep lobe
continuous around posterior border of
mylohoid

65. EXTENT OF GLAND
Superficial part  digastric triangle &
reaches forward  anterior belly of digastric
Posterior to it  stylomandibular ligament
which separates it from parotid gland
Superiorly, extends medial to mandible
Inferiorly, it approaches the greater cornu of
hyoid
this serves a landmark when marking
incision for removing the gland

66. DEEP PART OF GLAND
Extends forward to posterior end of
sublingual gland
Lies b/w mylohoid (infero-laterally)
& hyoglossus and styloglossus
(medially)
Posterior end is continuous with
superficial lobe of gland

67. CAPSULE
Partially enclosed between 2 layers
Derived from deep cervical fascia extending
from greater cornu of hyoid
Superficial Layer is attached to base of
mandible
Deep layer attached to mylohyoid line of
mandible
Unlike parotid fascia, it is loosely attached to
the gland; because of the loose texture of
interlobar & interlobular connective tissue

68. RELATIONS
Inferolateral surface- covered by
Skin
Superficial fascia containing
platysma and cervical branches of
facial N
Deep Fascia  Facial Vein &
Submandibular Nodes (in contact with
gland/ some embedded in it)
facial artery loops downwards and
forwards between the bone and the
gland
Lateral surface is in relation with
submandibular fossa & medial
pterygoid muscle.
Facial artery

69. Medial surface
Anterior part is related to mylohyoid muscle, nerve and
vessels
Middle part - Hyoglossus, styloglossus, lingual nerve,
submandibular ganglion, hypoglossal nerve and deep lingual
vein
Posterior Part - Styloglossus, stylohyoid ligament, 9th nerve
and wall of pharynx

70. DEEP PART
• Small in size
Deep to mylohyoid and superficial to hyoglossus and styloglossus
 Posteriorly continuous with superficial part around the posterior border of
mylohyoid
Anteriorly  posterior end of sublingual gland

71. SUBMANDIBULAR DUCT
 Wharton’s duct
emerges from the sublingual portion of the
gland.
 5cm long
 Thinner than parotid duct
 Tributaries  from superficial lobe of gland
 Traverses the deep lobe
 Duct runs forwards on hyoglossus between lingual and
hypoglossal N.
 At the ant. Border of hyoglossus it is crossed by lingual
nerve
 Opens in the floor of mouth at the side of frenulum of
tongue

72. Long, Has a tortous uphill course
Secretions  against gravity  increased
chances of retention
Also, mineral content is high (Ca++)
Increased retention + high mineral content
High incidence of calculus & inflammatory
pathologies

73. SUBMANDIBULAR GANGLION (LANGLEY’S
GANGLION)
Topographically, it’s linked to the trigeminal nerve (lingual nerve) but functionally it’s related to the facial nerve
(via its chorda tympani branch).

74. BLOOD SUPPLY AND LYMPHATICS
• Arteries  Branches of facial and lingual arteries
• Veins  Drains to the common facial or lingual vein
• Lymphatics  Deep Cervical Nodes via submandibular nodes

75. NERVE SUPPLY
Sensory fibers  lingual branch of mandibular nerve
Sympathetic fibers  preganglionic fibres originate from
T1 spinal section
Parasympathetic  secretomotor from superior salivary
nucleus of facial nerve
Preganglionic  sensory root of facial nerve  geniculate
ganglion  facial nerve chorda tympani & lingual nerve
 submandibular ganglion
Postganglionic  ganglionic to submandibular gland

76. FASCIAL ANATOMY
• Gland is surrounded by the middle layer of the deep cervical fascia.
• Fascia is clinically relevant during surgery of this region because the marginal mandibular branch
of the facial nerve lies superficial to this fascia and facial vein.
• Facial nerve branch is deep to the fascia surrounding the platysma muscles.
• The surgeon can approximate the location of the nerve as lying superior to a line two finger
breadths below the angle of the mandible.
• In appropriate cases, the surgeon can protect the nerve without direct identification by dividing
the anterior facial vein at the inferior surface of the gland and elevating the vein with the fascia.

77. ARTERIAL ANATOMY
• Facial artery courses deep to the posterior belly of the
digastric muscle
• Continues superiorly, usually indenting the posterior
portion of the submandibular gland.
• Exiting the superior aspect of the gland, the artery then
loops around the inferior border of the mandible,
leaving a small indentation in the bone, known as the
facial notch.
• Here, the artery is in close approximation to the lower
branches of the facial nerve as it courses superiorly into
the face.
• Artery is standardly ligated in two positions, at the
inferior border of the mandible and superior to the
posterior belly of the digastric muscle

78. VENOUS ANATOMY
• Anterior facial vein is adjacent to the facial artery
• The anterior facial vein then coalesces with the posterior facial vein
and descends over the midportion of the gland forming the common
facial vein. Inferiorly, this vein lies lateral to the gland

79. NEURAL ANATOMY
Lingual Nerve
he lingual nerve is attached to the deep surface
of the submandibular gland at the
submandibular ganglion.
The Hypoglossal Nerve
travel anteroinferiorly to the lingual nerve and
is deep to the lingual nerve and submandibular
duct.
readily identified in the submandibular triangle
with gentle dissection just posterior to the
junction of the anterior belly of the digastric
muscle with the inferior attachment of the
mylohyoid muscle.

80. The sublingual and submandibular glands can be palpated bimanually throughout
their lengths in the floor of the mouth
CLINICAL EXAMINATION

81. SURGICAL PLANES OF THE
SUBMANDIBULAR REGION
• After giving incision, a surgeon must bear in mind that deep structures in this
region are ordered in 4 muscular planes.

82. FIRST MUSCULAR PLANE
major structures in this are (a) digastric muscle and (b)
majority of the superficial part of the submandibular
gland.
Notice that superficial part of the submandibular gland
partially overlaps both anterior and posterior bellies of
the digastric muscle
SECOND MUSCULAR PLANE
major structures in this plane are (a)
mylohyoid muscle and (b) mylohyoid
nerve and vessels

83. THIRD MUSCULAR PLANE
major structures in this plane are (a) lingual and
hypoglossal nerves, which convey with every
other near the anterior border of hyoglossus, (b)
deep part of thesubmandibular gland and
submandibular duct, (c) submandibular ganglion
and (d) styloglossus muscle being crossed
superficially by the lingual nerve
FOURTH MUSCULAR PLANE
major structures in this plane are
genioglossus muscle, middle
constrictor of the pharynx and lingual
artery and its branches

84. SURGICAL APPROACHES TO
SUBMANDIBULAR GLAND

85. David Beahm D, Pelaez LL, Nuss DW, Schaitkin B, Sedlmayr JC, Walvekar RR. Surgical Approaches to the Submandibular Gland: A Review of Literature. The Laryngoscope.

87. Lateral transcervical approach
 6cm incision in placed in lateral neck crease
approximately 2 to 3 centimeters below the lower
edge of the mandible
 Subplatysmal skin flap is developed and the
marginal mandibular nerve is identified and
protected.
 Incision line runs within skin crease in neck
atleast 3cm below lower border of mandible to
avoid  the risk of injury to mandibular branch
of facial nerve
 It should be approximately 5cm long
 Lower the incision within neck  better the post
operative cosmetic result
 But lower the incision  difficulty in operating in
dissecting upwards to reach the gland

88. Submental approach
midline horizontal incision just superior to the
submental-cervical crease at the level of the hyoid
bone, (4.5 ± 1.9 cm).
The dissection differs from the traditional approach
in that the anterior free edge of the gland is first
encountered

89. Retroauricular approach
Roh also described
main advantage is the improved cosmesis

90. Transoral approach
An incision is made in the floor of mouth from
the submandibular papilla to the retromolar
trigone.
Downton D, Qvist G. Intra-oral excision of the submandibular gland. Proceedings of the Royal Society of Medicine. 1960 Jul;53(7):543.

91. Endoscopic-assisted transoral approach
Guerrissi JO, Taborda G. Endoscopic excision of the submandibular gland by an intraoral approach. The Journal of craniofacial surgery. 2001 May;12(3):299-303.
Endoscopic approaches to the SMG can be further classified as ”endoscopy assisted” and
“completely endoscopic” approaches.

92. SUBLINGUAL
GLAND

93. INTRODUCTION
Smallest of the three glands
Mixed gland , predominately mucous
weighs nearly 3-4 gm , Almond-shaped
Lies beneath the oral mucosa in contact
with the sublingual fossa on lingual aspect
of mandible.

94. RELATIONS
SUBLINGUA
L GLAND
Superiorly--
Mucosa of
oral floor,
raised as
sublingual
fold
Posteriorly --
Deep part of
Submandibul
ar gland
Laterally --
Mandible
above the
anterior part
of mylohyoid
line
Inferiorly--
Mylohyoid
muscle
Medially --
Genioglossus
and separated
from it by
lingual nerve
and
submandibular
duct
Anteriorly--
end of
opposite
gland

95. DUCTS OF GLAND
Anterior segment  drains in bartholins duct floor of mouth
or in anterior segment of submandibular duct
Posterior segment  8-20 ducts or Ducts of Rivinus
Most of them open directly into the floor of mouth. Few of
them join the submandibular duct.

96. SIGNIFICANCE
Secretions are thick and mucoid in nature
Excretory ducts are superficially located, hence
easily damaged
Any trauma / infection  salivary retention &
formation of mucous retention cyst (Ranula)

97. BLOOD SUPPLY AND LYMPHATICS
Branches of facial and lingual arteries supply the
sublingual gland and the corresponding veins drain
it.
Lymph vessels into submandibular and deep cervical
nodes

98. NERVE SUPPLY
Sensory fibers  lingual branch of mandibular
nerve
Sympathetic fibers  plexus on facial artery
Parasympathetic  secretomotor from superior
salivary nucleus of facial nerve
Preganglionic  sensory root of facial nerve 
geniculate ganglion  facial nerve chorda tympani
& lingual nerve  submandibular ganglion
Postganglionic  ganglionic to submandibular gland

99. APPROACHES TO SUBLINGUAL GLAND
• Simple excision of sublingual gland
linear incision in floor of mouth parallel to and lateral to submandibular duct
This incision should not extend posterior to 1st molar to avoid injury to lingual

100. Modified L-shaped surgical approach

101. REFERENCES
• Norton NS. Netter's head and neck anatomy for dentistry e-book. Elsevier Health Sciences;
2016 Sep 13.
• Gray's anatomy: the anatomical basis of clinical practice. Elsevier Health Sciences; 2015 Aug
7.
• Oral and maxillofacial surgery –by Rajiv Borle
• Head, neck and brain – Human anatomy – BD Chaurasia
• Stell and Maran’s – textbook of head and neck surgery and oncology
• Salivary gland pathology - Rankow

102. Stay home, stay safe