The document discusses the anatomy and pathologies of the major salivary glands. It details the location and structure of the parotid, submandibular, and sublingual glands. It also describes common disorders that can affect the salivary glands such as infections, tumors, duct obstructions, and systemic conditions. Physical examinations, imaging tests, biopsies and their roles in diagnosis are outlined.

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. Salivary glands are exocrine glands that produce saliva
through a series of ducts. Paired parotid, submandibular,
and sublingual glands constitute the major salivary glands.
Minor salivary glands, numbering 500-1000, are found
throughout the submucosa of the nasopharynx and
tracheobronchial tree. They are concentrated in the oral
cavity apart from the anterior hard palate and gingiva
where there is a relative paucity of glands. Under the
control of the parasympathetic nervous system, the major
salivary glands are responsible for the principal portion of
saliva produced, which can be as much as 1.5 liters per
day

4. The minor salivary glands contribute only a small
percentage of the overall volume of saliva, but they are
particularly important for supplying the mucus layer that
protects the tissues of the oral cavity and upper
respiratory tract. Saliva comprises mainly water, but also
contains enzymes, mucus, glycoproteins, electrolytes, and
antibacterial compounds that function together to perform
several important roles, including lubrication to aid in
swallowing, digestion of starches with salivary amylase,
modulation of taste, protection against dental caries, and
defense against pathogens

5. All of the major glands are in areas of significant
anatomical complexity. The parotid gland is intimately
associated with the facial nerve; the submandibular
gland with the facial, lingual and hypoglossal nerves,
and the sublingual gland with the lingual nerve and
multiple veins (1)

6. The parotid gland, the largest of the salivary glands, is
palpable over the ramus of the mandible and is bounded
posteriorly by the sternocleidomastoid muscle and the
mastoid process. The parotid gland extends superiorly
from the level of the external auditory canal and
zygomatic arch to the angle of the mandible inferiorly and
is separated medially from the carotid sheath by the
posterior belly of digastric muscle, the styloid process,
and its associated muscles. The gland is invested by the
superficial layer of deep cervical fascia, which is
thickened anteriorly and inferiorly to the gland to form
the stylomandibular ligament (2)

7. The parotid gland is frequently described as having a
superficial and a deep lobe separated by the facial nerve.
The larger superficial component accounts for the majority
of the gland and lies on the lateral surface of the masseter
muscle. The remaining deeper component extends
medially through the stylomandibular tunnel between the
posterior border of the ramus of the mandible, the
stylomandibular ligament, and the skull base superiorly.
The contents of the parotid gland include lymph nodes,
facial nerve, external carotid artery, and retromandibular
vein (2)

8. The parotid duct (Stensen’s duct) is around 7 cm long.
It emerges from the anterior surface of the parotid before
coursing over the masseter muscle, a finger’s breadth
inferior to the zygomatic arch, and turns abruptly at 90
degrees to pierce the buccinator muscle and buccal fat.
The duct then passes inferiorly and obliquely to enter the
oral mucosa at the level of the second upper molar
tooth. Accessory parotid tissue, anterior to and separate
from the parotid, is seen in 20% of the population and
lies superficial to the masseter muscle and cephalic to the
duct (2)

9. The parotid gland has both sympathetic (mainly
vasoconstrictor) and parasympathetic (secretomotor)
innervation. The sympathetic fibers arise from the carotid
plexus and the parasympathetic fibers arise from the
auriculotemporal nerve. The secretomotor component of
the auriculotemporal nerve arises from the
glossopharyngeal cranial nerve that has joined the
auriculotemporal nerve just below the skull base. The
secretomotor parasympathetic fibers leave the
auriculotemporal nerve within the parotid gland; by the
time the nerve crosses the temporomandibular joint, it
contains only sensory fibers from the scalp (2)

10. The submandibular gland is the second largest of the
salivary glands and fills the major portion of the
submandibular triangle. Although anatomically not
divided, it is often described as having superficial and
deep lobes that connect around the posterior border of the
mylohyoid muscle. The larger palpable superficial lobe
lies wedged between the mandible and superficial aspect
of the mylohyoid muscle and is separated posteriorly
from the parotid by the stylomandibular ligament. The
superficial relations of the gland are platysma, the
superficial layer of deep cervical fascia, anterior facial
vein, and part of the mandibular branch of the facial
nerve (2)

11. The facial artery has a tortuous course arriving at the
posterior surface of the submandibular gland and then
passes over and indents the superior aspect of the gland.
The artery turns inferiorly, between the gland and medial
cortex of the mandible, to reach its inferior border and
subsequently supplies the face. The smaller deep lobe of
the gland lies deep to the mylohyoid muscle and is
palpable in the floor of the mouth. Posteriorly the deep
lobe abuts the hyoglossus muscle and at this site is in
contact with the lingual and hypoglossal nerves as they
pass forward into the tongue (2)

12. The main duct of the submandibular gland; Wharton’s
duct exits anteriorly from the gland and angles sharply
around the posterior border of the mylohyoid muscle
before passing anteriorly and superiorly between the
hyoglossus and mylohyoid muscles. The duct continues
anteriorly and passes medial to the sublingual gland and
lateral to genioglossus beneath the mucosa of the floor of
the mouth to open just lateral to the frenulum (2)

13. The lingual nerve “double-crosses” the duct, commencing
lateral to it, and then passing inferior to the duct, and
finally crossing the duct again to lie medial to it. The
submandibular gland drains to adjacent submandibular
lymph nodes. As with the parotid, the sympathetic
innervation arises from the carotid plexus and the
parasympathetic from both facial and glossopharyngeal
nerves (2)

14. The sublingual gland is the smallest of the major salivary
glands. It is a flat oblong shaped structure that lies
immediately below the mucosa of the floor of the mouth.
Laterally it lies against the sublingual groove of the
mandible, superior to the mylohyoid muscle, and medially
is separated from the genioglossus by the distal half of
Wharton’s duct and the lingual nerve. The sublingual gland
drains via a number of small ducts (approximately 20)
either directly into the floor of mouth or into Wharton’s
duct itself. The lymph drainage is into submental and
submandibular lymph nodes (2)

15. Major salivary glands

16. The parotid gland with the traversing
branches of the facial nerve

17. Detailed relations of the submandibular salivary gland

18. Anatomy of submandibular and sublingual glands

19. Salivary glands may be affected by a wide range of
disorders. The glands can be involved with acute and
chronic inflammatory processes, give rise to benign and
malignant tumors, manifest congenital abnormalities or
represent involvement of a systemic disorder. Further,
partial or complete obstruction of the ductal element can
occurs. The majority of patients with a salivary gland
disorder have a limited number of symptoms: pain,
swelling, oral dryness, excessive salivation, and taste
abnormalities, either singly or in combination. This can be
acute, recurrent, or chronic. A thorough history and
physical examination are often adequate to recognize and
differentiate many of these disorders

20. The superficial location of the salivary glands easily
permits inspection and palpation so that a thorough
physical examination, combined with a detailed history,
often provides sufficient information for a clinical
diagnosis. Some complaints are characteristic and may lead
directly to a diagnosis. Pain and swelling associated with
meal times is a classical example and is strongly indicative
of the presence of a salivary calculus (3) . Further,
information about the general condition and medical history
of the patient should be obtained. A number of systemic
disorders are associated with salivary gland dysfunction,
e.g. hormonal imbalances

21. The age and sex of the patient are important since
some salivary gland disorders tend to be age- or sex-
related. Mumps, for instance, usually occurs during
childhood (4) , whereas Sjögren's syndrome generally
presents in middle aged females (5). Acute swelling
of sudden onset may be acute sialadenitis associated
with bacterial or viral infections. A diffuse swelling of
salivary glands associated with dryness of the mouth
and eyes may be Sjögren's syndrome

22. Nodular enlargements of a minor or major salivary gland
with a history of slow growth over many years suggest a
benign neoplasm. Nodular enlargements of a minor or
major salivary gland with a history of rapid growth over a
few months suggest a malignant neoplasm. However, some
patients with salivary gland cancer present with a slowly
enlarging, painless mass. Generally, benign tumor is firm,
painless, slow growing swelling, that is readily movable.
This is an important sign, since most malignant neoplasms
are indurated, and cannot be displaced, being firmly
attached to underlying and overlying structures

23. Physical examination should document size of the mass,
mobility of the mass, pain with palpation, any limitation in
jaw opening, buccal involvement or pharyngeal
asymmetry, skin or scalp lesions indicative of primary
malignancy. It is important to emphasize that painful facial
paralysis or another neurologic deficit associated with a
salivary gland mass strongly suggests a possible malignant
cause. Intraoral examination should investigate the palate
and lateral pharynx for asymmetry suggesting
parapharyngeal extension. The neck is then palpated to
detect a lymphadenopathy. Occasionally, however, the
clinician may fail to reach a proper diagnosis, in this
situation, some diagnostic aids are required

24. Bimanual examination of the parotid and submandibular
salivary glands

25. Conventional radiography with or without contrast
sialography are largely non-contributory. It aids in
identifying mainly salivary stones and calcifications.
Sialograms, although still mentioned by most texts, are
really an historic investigation. This technique requires
cannulation of the duct, instillation of contrast material,
and exposure to radiation. They are technically difficult to
perform and are painful to the patient. Furthermore, they
generally only illustrate the duct system and not the gland
proper (1). Ultrasonography, computed tomography,
magnetic resonance imaging is helpful in assessment of
the parenchyma of the salivary glands

26. Salivary stones identified by plain radiographs

27. Normal parotid and submandibular sialograms

28. Chronic infection shows the presence of small numerous
dilatations in the ducts, and many small cavitations
in the globular pattern

29. Ultrasound examination of salivary glands with a high
resolution transducer is found to be a highly sensitive, a
non-invasive method for salivary gland evaluation (6). The
normal echogenicity of all major salivary glands,
including the parotid gland, is generally homogeneous and
hyperechogenic in comparison to adjacent muscles. The
echogenicity depends on the amount of intra-glandular
fatty tissue. Ultrasound is useful in assessing the size of
the gland and the vascularity of the lesion. It differentiates
between a focal and diffuse disease, cystic and solid
lesions. US also guides fine needle aspiration biopsy.
Generally, the normal gland is hyperechogenic, whereas
the diseased gland varies in hypoechogenicity

30. Gray-scale image of normal parotid gland. The parenchyma is hyperechogenic
compared to the masseter muscle 1. The position of the US probe is
shown in the inset diagram

31. Gray-scale image shows the typical appearance
of a pleomorphic adenoma (arrows). The lesion
is hypoechoic and lobulated with distinct borders
Malignant tumor in the parotid gland

32. Computed tomography(CT) scans of the salivary glands
are useful in delineate the extent of the lesion and its
relation to adjacent structures. CT scans help in
differentiating the benign and malignant neoplasms of
salivary glands. The irregular tumor margin and
surrounding tissue infiltration is the characteristic feature
of malignancy (7). Exposure to ionizing radiation and the
administration of IV contrast are the only significant
disadvantages to CT scanning

33. Axial CT scan of the neck showing a
left parotid gland pleomorphic
adenoma
Axial CT image shows enlarged left
submandibular gland (thick white arrow)
associated with destruction of the
adjacent mandible

34. The impact of MRI is in the soft tissue contrast that can be
obtained, non-invasively. The relaxation times of tissues
can be manipulated to bring out soft tissue detail. Typical
pulse sequences for head and neck and brain imaging
include spin-echo T1, spin-echo T2, and proton density
(PD). Any one of these can be obtained in the three
standard orientations of axial, coronal, and sagittal planes.
In general, CT is considered the best single method for
assessment of inflammatory diseases and MR imaging is
considered the best single method for assessment of
salivary gland tumors (8,9)

35. MRI showing right
parotid tumor with
extension into the
deep lobe

36. Right parotid pleomorphic adenoma on axial and coronal MRI scans of the
neck. These masses are typically solitary, non-infiltrating and well
demarcated. The heterogeneous appearance may be secondary to
hemorrhage, calcification, and necrosis

37. Open surgical biopsy of a suspected gland tumor is
contraindicated. If the lesion is contained within the
capsule of the gland, open biopsy will spill tumor cells
into the surrounding tissue planes. Fine needle aspiration
cytology (FNAC) can be used, but lakes accuracy.
Currently, ultrasound guided core biopsy (USCB) has
been the standard for obtaining a biopsy. The technique
showed a higher sensitivity (96%) and specificity (100%) ,
and a lower complication rate (10) . The low complication
rate has been attributed to the ability of US to visualize the
vessels and allow the operator to infer the position of
facial nerve branches

38. Ultrasound guided core biopsy.
Biopsy undertaken with spring
loaded biopsy automated
device, 22 mm throw, 18G needle

39. Developmental; Aplasia, Atresia, and Aberrancy.
• Aplasia is the complete absence of one or more
salivary gland.
• Atresia is the congenital occlusion or absence of
salivary ducts.
• Aberrancy is an anatomic variant wherein the normal
salivary gland develops at an abnormal position.
Staphne’s bone cavity is an example

40. Inflammatory; sialadenitis is an inflammatory condition
affecting the salivary glands. Parotid is the most
commonly involved gland. Usually, the condition affects
dehydrated, debilitated elderly patients. It can also affects
adults, adolescents, children, or patients with medication
on tricyclic antidepressants and tranquilizers. The main
etiologic factors for sialadenitis can be either infectious or
non-infectious factors. Bacterial and viral agents can be
the cause of sialadenitis. Bacterial sialadenitis is caused
because of retrograde spread of infection secondary to
decreased salivary flow or ductal obstruction

41. Ductal obstruction can be due to sialolithiasis ,
strictures within the ductal system and common in
submandibular salivary glands or due to pressure effect
from adjacent tumors. Staphylococcus aureus is the most
common etiologic agent for acute bacterial parotitis, but
may be caused by any commensal bacteria of the oral
cavity. Parotid gland is the most common salivary gland
involved in acute bacterial sialadenitis. The patient may
present with fever and dehydration (11). Clinically there is
unilateral swelling of involved gland which is tender to
palpation with purulent discharge over Stensens duct.
Sudden pain at the angle of the jaw is usually a complaint

42. Acute bacterial sialadenitis is characterized by rapid onset
of pain and swelling. In contrast, chronic sialadenitis is
characterized by intermittent recurrent episodes of tender
swelling. Treatment is usually conservative including large
doses of antibiotics, improved oral hygiene, and increased
fluid intake. On the contrary, some patients with severe
infections required surgical drainage. The parotid capsule
and septations required wide exposure and extensive deep
incisions parallel to the facial nerve branches to exteriorize
the diseased gland

43. Sialadenitis; parotid salivary gland

44. Mumps, one of the classic childhood infections, is spread
by droplets or by direct spread from oropharyngeal
secretions that contain the paramyxovirus. 85% of cases
occur in children younger than 15 years. The disease is
characterized by grossly enlarged and modestly tender
parotid glands. Parotid stimulation caused pain in the
gland and ear. Most cases are bilateral, though it
commonly begins on one side. Diagnosis is confirmed
through viral serology

45. Immunization with measles, mumps, and rubella (MMR)
vaccine is currently world wide employed. The child
received a first dose at one year age, and a second dose by
four to six years of age. Vaccination is 88% effective in
preventing mumps and has reduced the incidence by
99% (12) . Treatment involves supportive measures,
including hydration, oral hygiene and pain control. Edema
typically resolves over several weeks. Occasionally,
however, the condition may be complicated by
meningoencephalitis, pancreatitis, orchitis, or deafness
especially in young adults

46. Mumps

47. Salivary stone (sialolithiasis)
Sialolithiasis is the most common disease of salivary
glands (13). The prevalence of submandibular gland
sialolithiasis is 80%, 19% in the parotid and 1% in the
sublingual glands. The exact cause of stone formation is
not known, but most agree that the stone begins as a small
nidus and grows by concentric deposition of inorganic
crystals in an organic matrix. Calculi are much less
common in the parotid gland than in the submandibular
gland, possibly because the secretions are more serous
than the mucoid saliva of the submandibular gland.
Calculi do not cause symptoms until they become large
enough to impede the flow of saliva

48. Partial obstruction causes the gland to inflate itself with
marked stimulation to secrete saliva, as occurs in eating.
The gland swells while eating and soon becomes painful.
The swelling and pain subside in 30-60 minutes only to
recur at the next meal. Total obstruction causes pain,
swelling, and infection. Complications of the calculi
include infection within the gland (sialadenitis), scarring
with stenosis, and fistula formation. The diagnosis is
confirmed by imaging studies including plain radiographs
with or without injection of contrast media into the duct.
CT scans also show single or multiple stones. Treatment is
removal of the stone

49. The surgical approach depends on the location of the
stone. Submandibular stones that can be palpated and are
located in the anterior floor of mouth can be excised
intraorally, usually under local anesthesia. The first stage
is to pass a suture into the floor of the mouth around the
duct proximal to the position of the stone. This prevents
the stone from being displaced backwards during the
operation. Gentle traction on the suture will then lift the
duct upwards making it more accessible in the floor of the
mouth. An incision is made in the mucosa along the line of
the duct and over the stone. Often the calculus will be seen
through the duct wall and an overlying incision
immediately releases it

50. In case of adhesion, the calculus can be gently mobilized
and freed with the careful use of a fine artery clip or small
dental excavator. The duct should be gently irrigated with
sterile saline or water both proximally and distally to
ensure that any further epithelial casts or gravel are
removed. If these are retained, they readily act as foci for
further stones to form. The stay sutures are removed and
the mucous membrane of the floor of the mouth is closed
with two or three resorbable sutures. No attempt should be
made to close the duct walls as this would result in scarring
and stricture formation leading to further obstruction

51. Ligation of the duct posterior to
the sialolith, in order to avoid
distal displacement of the
stone during surgical procedure
Incision along the length of the duct
where the sialolith is located

52. Exposure and removal of
the sialolith
Operation site after
suturing

53. Preservation of the submandibular gland has always
been attempted in the treatment of sialolithiasis by
transoral resection of the salivary stone. However,
sialoliths lodged in the posterior third of the duct
system, in the hilum, or still further within the
glandular parenchyma present a problem. Various
techniques of sialodochotomy have been described
whereby a major point of concern has always been the
risk of injury to the lingual nerve which courses in
close proximity to the Wharton duct. Surgical excision
of the gland is recommended in cases of large,
difficult to reach, deeply located sialolith (14)

54. Incision for submandibular
gland excision
Gland bed after resection
Excised gland. Please note the
size and number of stones

55. Minimally invasive techniques have now gained
precedence owing to reduced morbidity, retaining a
functional gland after removal of calculi and the procedure
being day-care and performed under local anaesthesia (15) .
Sialedenoscopy, which is a non invasive technique can be
use to manage large sialoliths as well as ductal
obliteration. The duct is anesthetized and dilated to insert a
telescope for inspection. A working channel in the
telescope permits irrigation, suction, and insertion of
forceps, wire loop, or even laser energy via a glass fiber to
remove the calculi

56. Sialedenoscopy, inset grasping forceps and wire baskets

57. Conservative methods of treatment such as, extracorporeal
shock wave lithotripsy (ESWL), and endoscopic
intracorporeal shock wave lithotripsy (EISWL) techniques
should be considered as an alternative to surgical excision,
because of less damage to the adjacent tissues during the
procedure (16). The shock-waves are generated
extracorporeally by using Piezoelectric and
electromagnetic techniques or intra-corporeally using
electro-hydraulic, pneumatic or laser endoscopic devices

58. Endoscopic intracorporeal
pneumatic shock wave lithotripsy
Extracorporeal shock wave lithotripsy

59. Cystic lesions; Mucocele and Ranula
Mucocele is the most common disorder of minor salivary
glands and is caused by accumulation of mucous inside
the tissues. Based on histopathologic findings, these
lesions can be classified as mucous retention or mucous
extravasation cysts, former being characterized by the
presence of epithelial tissue while later by a covering with
granulation tissue. Mucous extravasation cyst is generally
regarded as being of traumatic origin, such as lip biting
while the mucous retention cyst results from obstruction
of the duct of a minor or accessory salivary gland (17).
Clinically, the lesion appears as a soft, discrete, nonpainful
swelling of the mucosa

60. The lower labial mucosa is the most frequent site of
involvement, but it can develop at virtually any location
where minor salivary glands occur, including the soft
palate, retromolar region, and buccal mucosa. When
mucocele is located in the floor of the mouth it appears as
“Belly of a frog” and is called as a “Ranula”. If the lesion
is localized superficially, it presents a bluish coloring due
to the superficial capillary network that appears through it.
When located more deeply in tissues, its color is similar to
that of the mucosa. Prognosis of the lesion is favorable
and is conventionally treated by excision of the gland
along with the associated overlying mucosa and glandular
tissue down to the muscle layer (18)

61. Mucocele, clinical photo
Ring block anesthesia
Elliptical incision

62. Dissection Underlying muscular layer
Undermining wound margins Closure

63. Ranula
By definition ranula is defined as a mucus filled cavity in
relation to sublingual gland present in the floor of mouth.
Mucus extravasation is the most widely accepted
developmental factor. The name "ranula" has been derived
from the Latin word “rana” which means "frog". Ranula
resembles a frog's translucent underbelly or air sacs.
Ranulas are characterized by large (>2 cm) cystic cavities
and appear as a tense fluctuant dome-shaped vesicles,
sometimes with a bluish hue, typically present unilaterally.
A clinical variant "plunging ranula” occur when the fluid
from the obstructed gland dissects between the fascial
planes and muscle of the base of the tongue to the
submandibular space, causing swelling in the neck

64. The presence of an ectopic salivary gland on the cervical
side of the mylohyoid muscle may explain the
development of plunging ranulas without intraoral
components. Projection of the sublingual gland through
the hiatus between anterior and posterior part of the
mylohyoid muscle is another explanation (19). Additionally,
plunging ranulas may develop iatrogenically after single
or multiple attempts at eliminating oral ranulas by either
marsupialization or simple drainage (20)

65. Sublingual ranula

66. Plunging ranula

67. Many treatment modalities have been applied for the
management of ranulas. These include, marsupialization,
excision of ranula only, and excision of ranula along with
sublingual salivary gland. Marsupialization, however, has
been the most popular. More recently, the
micromarsupialization technique has been utilized for the
treatment of ranula. The technique is simple, minimally
invasive, and involves placing multiple silk sutures in the
dome of the cyst. The suture was maintained for
approximately 30 days. The basic idea of micro-
marsupialization is to establish drainage of saliva and
formation of new permanent epithelized tract along the
path of sutures (21)

68. Ranula, marsupialization

69. Salivary gland tumors
Salivary gland tumors are rare and the majority of these
neoplasms are benign and only 20% are malignant.
Tumors can occur in both the major and minor salivary
glands. 80% of major salivary gland tumours occur in the
parotid glands, while most minor salivary tumours are
located in the palate (22). As a general rule in clinical
practice, the smaller the salivary gland is, the more likely
the tumor is malignant. In the parotid glands, 20–25% of
the tumours are malignant. This rises to 40% for the
submandibular glands, and more than 90% of sublingual
gland tumours are malignant (23)

70. Salivary gland tumours in the parotid or submandibular
glands usually present as an enlarging mass. This may be
associated with neurological symptoms such as facial
nerve paralysis or pain if the tumor is malignant. Minor
salivary gland tumours present as a submucosal intraoral
mass which subsequently ulcerates. Clinical features
suspicious for malignancy include ipsilateral facial nerve
palsy, sudden tumor growth, pain, tumor fixation to the
overlying skin or underlying muscle, and cervical
lymphadenopathy. Most patients who develop malignant
salivary gland tumors are in the sixth or seventh decade of
life

71. Pleomorphic adenoma (benign mixed tumor) of the
salivary glands is a benign, slowly growing neoplasm that
has a predilection to the parotid where 80% of these
tumors arise (22) . In the majority of cases the tumor arises
in the superficial lobe lateral to the facial nerve. It is often
firm, nodular, painless and almost always unilateral.
Women are more affected than men. Facial nerve function
is usually not affected, even in very large tumors. About
2/3 arise in the superficial lobe of the parotid, but
occasionally, they extend medially into the
pharynx. Malignant degeneration could occur in 3 - 5 %
of the cases

72. Warthin's tumor (benign papillary cystadenoma
lymphomatosum) is the second most common benign
tumor of the parotid gland. It accounts for 2-10% of all
parotid gland tumors. Unlike the pleomorphic adenoma, it
is more common in older white men and is likely to be
bilateral in 10% of the cases (24). Benign tumors require
careful excision as they are encapsulated and residual
tissue after surgery can increase the risk of tumor
recurrence. Minor salivary gland lesions have a good
prognosis and can be treated safely by conservative local
excision

73. Surgically excised lesion
Axial image, T1- weighted MRIPleomorphic adenoma, palate

74. Pleomorphic adenoma, parotid gland

75. In past decades, surgical management of pleomorphic
adenoma of the parotid gland consisted predominantly of
local excision or “enucleation technique”, a procedure that
yields recurrence rates from 20% to 45%. The hypothesis
for recurrence is that microscopic portions of tumor
perforate the capsule and are shared off resulting in a
subtotal removal. The main complication that can occurred
during surgery is temporary/ permanent facial nerve
paralysis. A further unwanted complication of recurrent
tumors is parotid cancer development. The current
replacement of simple enucleation of tumor with other
surgical approaches like: superficial parotidectomy, total
parotidectomy, and extracapsular dissection as treatment
of choice reduced dramatically the incidence of tumor's
recurrence and complications (25)

76. Incision for parotidectomy.
The incision curves behind the
earlobe and is extended
in a crease of the neck
Skin flap raised

77. All branches of facial nerve following superficial parotidectomy

78. Mucoepidermoid carcinoma is the most common
malignant neoplasm of the parotid gland. It constitutes
approximately 30% of all malignant tumors of the salivary
gland and occurs most frequently in the parotid gland (26).
Adenoid cystic carcinoma is the second most common
malignant tumor accounting 2-6% of all parotid gland
tumors. Adenoid cystic carcinoma is particularly nasty in
that it has a very high tendency to invade and travel along
nerves (27), making curative resections very difficult. Facial
weakness is sign of malignancy, and indicates a poor
prognosis

79. Complete surgical resection, with adequate free margins,
is currently the mainstay treatment for malignant salivary
gland tumours. However elective treatment of the N0 neck
region remains a controversial topic. Most patients with
early-stage lesions that are resectable generally tend to
undergo surgery as their initial therapeutic approach,
whereas those with advanced or unresectable cancers tend
to be treated with radiotherapy. Fast neutron therapy has
been used successfully in treating unresectable salivary
gland tumors (28). The role of postoperative chemo-
radiation for salivary gland malignancy is not well
established. Currently little is known about the efficacy of
chemotherapy in treating salivary gland tumours

81. 1. Lawler B, Pierce A, Sambrook PJ, et al. The diagnosis and surgical
management of major salivary gland pathology. Aust Dent J; 49: 9, 2004.
2. Beale T, Madani G. Anatomy of the salivary glands. Semin Ultrasound
CT MRI; 27: 436, 2006.
3. Cawson RA, Binnie WH, Barrett AW, Wright JM (eds). Oral disease.
Clinical & pathological correlations. 3rd ed. Edinburgh: Mosby; 167, 2001.
4. Lopez-Perea N, Masa-Calles J, Torres de Mier M, et al. Shift within age-
groups of mumps incidence, hospitalizations and severe complications in a
highly vaccinated population. Spain, 1998–2014. Vaccine; 35: 4339, 2017.
5. Stefanki A- L, Tomiak C, Plever U, et al. The Diagnosis and Treatment of
Sjögren’s Syndrome. Dtsch Arztebl Int; 114: 354, 2017.
6. Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands.
Otolaryngol Clin North Am; 42: 973,2009.
7.Choi DS, Na DG, Byun HS, et al . Salivary gland tumors: evaluation with
two-phase helical CT. Radiology; 214: 231, 2000.
8. Rabinov JD. Imaging of salivary gland pathology. Radiol Clin North Am ;
38: 1047, 2000.
9. Yousem DM, Kraut MA, Chalian AA. Major salivary gland imaging.
Radiology; 216: 19, 2000.

82. 10. Witt BL, Schmidt RL. Ultrasound-guided core needle biopsy of salivary
gland lesions: a systematic review and meta-analysis. Laryngoscope; 124:
695, 2014.
11. Ellies M, Laskawi R. Diseases of the salivary glands in infants and
adolescents. Head Face Med; 6: 1, 2010.
12.Centers for Disease Control and Prevention. Mumps vaccination.
http://www.cdc.gov/mumps/vaccination. html. Accessed January 14, 2014.
13. Alkurt MT, Peker I. Unusually large submandibular sialoliths: report of
two cases. Eur J Dent; 3: 135, 2009.
14. Soares EC, Costa FW, Pessoa RM, et al. Giant salivary calculus of the
submandibular gland. Otolaryngol Head Neck Surg; 140: 128, 2009.
15. McGurk M, Escudier MP, Brown JE. Modern management of salivary
calculi. Br J Surg; 92: 107, 2005.
16. Bodner L. Giant salivary gland calculi: diagnostic imaging and surgical
management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 94: 320,
2002.
17. Huang IY, Chen CM, Kao YH, et al. Treatment of mucocele of the lower
lip with carbon dioxide laser. J Oral Maxillofac Surg; 65: 855, 2007.

83. 18. Delbem AC, Cunha RF, Vieira AE, et al. Treatment of mucus retention
phenomena in children by the micro-marsupialization technique: Case
reports. Pediatr Dent; 22: 155, 2000.
19. Engel JD, Ham SD, Cohen DM. Mylohyoid herniation: gross and
histologic evaluation with clinical correlation. Oral Surg Oral Med Oral
Pathol; 63: 55, 1987.
20. Bridger AG, Carter P, Bridger GP. Plunging ranula: literature review and
report of three cases. Aust N Z J Surg; 59: 945, 1989.
21. Sandrini FA, Sant'ana-Filho M, Rados PV. Ranula management :
Suggested modifications in the Micro-marsupialization technique. J Oral
Maxillofac Surg; 65: 1436, 2007.
22. Speight PM, Barrett AW. Salivary gland tumours. Oral Diseases; 8: 229,
2002.
23. Rinaldo A, Shaha AR, Pellitteri PK, et al. Management of malignant
sublingual salivary gland tumors. Oral Oncol; 40: 2, 2004.
24. Belli E, Renzi G, Balestra FM, et al. Bilateral parotid voluminous
masses: a case report. J Craniofac Surg; 15: 165, 2004.
25. Guerra G, Testa D, Montagnani S, et al. Surgical management of
pleomorphic adenoma of parotid gland in elderly patients: Role of
morphological features. Inter J Surg; 12: S12, 2014.

84. 26. Boahene DKO, Olsen KD, Lewis JE, et al. Mucoepidermoid carcinoma
of the parotid gland. The Mayo clinic experience. Arch Otol Head Neck
Surg; 130: 849, 2004.
27. Ayadi K, Ayadi L, Daoud E, et al. Adenoid cystic carcinoma of the
parotid with facial nerve invasion. Tunis Med; 88: 46, 2010.
28. Douglas JD, Koh WJ, Austin-Seymour M, et al. Treatment of salivary
gland neoplasms with fast neutron radiotherapy. Arch Otol Head Neck Surg;
129: 944, 2003.