Retrograde dissection of facial nerve branches to identify main trunk. Dissection: - Dissection of superficial lobe as in superficial parotidectomy. - Identification of main trunk of facial nerve. - Ligation and division of retromandibular vein. - Dissection of deep lobe from surrounding structures like internal carotid artery, internal jugular vein, cranial nerves IX, XI, XII. - Ligation of branches of external carotid artery supplying deep lobe. - Complete removal of parotid gland. - Closure in layers over drain. - Post op facial nerve monitoring. - Risk of facial nerve injury is higher than superficial par

1. SALIVARY GLANDS
Dr. Ravindra Kumar Yadav (JR1)
DEPARTMENT OF GENERAL SURGERY

2. CONTENTS
• Introduction
• Classification
• Embryology
• Development
• Structural units
• Parotid gland
• Surgical landmarks of Facial nerve
• Submandibular gland
• Sublingual gland
• Minor salivary gland
• Superficial Parotidectomy
• Total Parotidectomy
• Submandibular gland excision
• MCQ’s

3. INTRODUCTION
• These are compound, tubular, acinous, exocrine glands.
• Ducts of which open into oral cavity.
• This glands secrete complex fluids called saliva.
• Which keeps the oral cavity moist and aid in mastication and
swallowing of food.
• The saliva also contains certain enzymes that has digestive and
protective function as well.

4. CLASSIFICATION
BASED ON THE SIZE
1. Major salivary glands.
2. Minor salivary glands.

5. Major Salivary Glands
• These lie distant to oral mucosa
and are connected via duct
system to the oral cavity.
Types - Three Pairs :
1. Parotid glands.
2. Submandibular glands.
3. Sublingual glands.
Minor Salivary Glands
• These are numerous.
• Approximately ~ 800 minor
salivary glands scattered
throughout the oral mucosa.
• Open directly into the surface of
the oral mucosa.

6. CLASSIFICATION
BASED ON THE TYPE OF SECERETION
1. Serous secreting glands.
(Eg : Parotid gland, Von Ebner’s gland)
2. Mucus secreting glands.
(Eg: Most of the Minor salivary glands & Sublingual gland)
3. Mixed secretion glands.
(Eg: Submandibular gland)

7. EMBRYOLOGY
OF SALIVARY GLANDS
Major glands develops from the ectoderm.
Are derived from the oral cavity epithelium
Which proliferates and burrows into the surrounding mesenchyme to
form a solid cord, Further branching and formation of acini and
development of the lumen of the glands occurs.
Minor glands develops from the endoderm.

8. DEVELOPMENT
OF SALIVARY GLANDS
Parotid gland is the first to develop 4th week
Followed by Submandibular gland 6th week
Followed by Sublingual gland 8th week

9. Frontal section of developing face

10. STRUCTURE AND DUCT SYSTEM
OF SALIVARY GLANDS

11. PAROTID GLAND
“Para = around ; Otic = ear”
• Definition: it is the largest salivary gland.
• Shape: Three sided pyramidal structure, with apex
directed downwards.
• Enclosed within the slit investing layer of deep
cervical fascia.
• Site: It lies on the side of the face, below the EAM,
between the ramus of the mandible and SCM.

12. Boundaries:
• Anteriorly: ramus of the mandible.
• Posteriorly:mastoid process & SCM.
• Medially:styloid process.
• Superiorly:external auditory meatus.
• Interiorly: separated by stylomandibular ligament
from submandibular gland.

13. PAROTID GLAND cont…d
Division: It is divided into
1. Superficial lobe
2. Deep lobe
3. Accessory lobe
• The superficial and the deep parts
connected to each others by an isthmus
while the accessory lobe lies above the
parotid duct

14. PAROTID GLAND cont…d
The gland has
• 4 surfaces: superior, superficial or
lateral surface , antero-medial and
postero-medial surfaces
• 3 borders: anterior and posterior
and medial borders
• 2 poles: upper and lower poles

15. PAROTID GLAND cont…d
Capsules: the gland is surrounded by two capsules:
• False capsule: derived from the investing layer of the deep
fascia, which later splits to enclose both submandibular and
parotid glands and inbetween it is thickened to form the
stylomandibular ligament.
• True capsule: which is a condensation of the connective tissue
of the gland

17. PAROTID GLAND cont…d
RELATIONS:
1. Superior surface :
Concave shape (base of pyramid)
Related to the:
• Cartilaginous part of external acoustic meatus.
• Posterior aspect of temporo-mandibular joint.
• Superficial temporal vessels.
• Auriculotemporal nerve.

18. PAROTID GLAND cont…d
RELATIONS:
2. Lateral surface:
Largest of all the 4 surfaces.
Covered with
• Skin,
• Superficial fascia & parotid fascia,
• Posterior fibres of platysma with risorus,
• Facial branch of great-auricular nerve,
• Superficial parotid lymph nodes.

19. PAROTID GLAND cont…d
RELATIONS:
3. Antero-medial surface:
• It is grooved by the posterior border of the ascending ramus of
the mandible.
• Lateral surface of TMJ.
• Messeter
• Medial pterygoid.
• Emerging Facial nerve branches

20. PAROTID GLAND cont…d
RELATIONS:
4. Postero-medial surface (Parotid Bed): related to
• The mastoid process and related muscles
(posterior belly of digasteric & Sternomastoid muscle)
• The styloid process:
and attached structures.
• Carotid sheath:
deep to the styloid process

21. PAROTID GLAND cont…d
RELATIONS:
Anterior border of the gland:
• It is convex border,
• It lies over masseter muscle.
• Separates superficial surface from antero-medial surface.
• It has the following structures come out form it
1. Terminal branches of the facial nerve
2. Transverse facial vessels
3. Parotid duct and the accessory parotid lobe

22. PAROTID GLAND cont…d
RELATIONS:
Posterior border of the gland:
Separates superficial surface from posteromedial surface.
Medial edge / pharyngeal border of the gland:
Separates anteromedial surface from the postermedial surface
Related to the lateral wall of pharynx

23. PAROTID GLAND cont…d
RELATIONS:
Upper pole of the gland:
It is concave surrounds the external auditory meatus
The following structures come out from it:
1. Temporal branch of the facial nerve
2. Auriculo-temporal nerve
3. Superficial temporal vessels

24. PAROTID GLAND cont…d
RELATIONS:
The lower pole of the gland:
It is tapering lies between the angle of the mandible and the
sternomastoid muscle superficial to the posterior belly of digasteric
The following structures come out from it:
1. Cervical branch of the facial nerve
2. Posterior facial vein and its anterior and posterior divisions
3. External carotid artery

26. PAROTID GLAND cont…d
RELATIONS:
Structures within the substance of the gland:
Vessels
1. External carotid artery
2. Transverse facial artery
3. Retromandibular vein
4. Superficial temporal vein
Nerve
1. Facial nerve

27. PAROTID GLAND cont…d
RELATIONS
The external carotid artery:
Course: Pierces the lower pole of the gland.
Termination: Divides into two terminal branches; the superficial
temporal artery and the maxillary artery behind the neck of the
mandible.

28. PAROTID GLAND cont…d
RELATIONS
The retromandibular vein:
Origin: It is formed within the gland substance by the union of the
superficial temporal and maxillary veins.
Termination: It divides near the lower pole into the anterior and
posterior divisions:
• The anterior division: joined by the anterior facial vein to form
the common facial vein.
• The posterior division: joined by the posterior auricular vein to
form the external jugular vein.

29. PAROTID GLAND cont…d
RELATIONS
The facial nerve: Facial nerve emerges from the stylomastoid foramen
as a single trunk.
Course: It enters the posteromedial surface of the gland.
Divides the gland into superficial and deep lobe.
Termination: It divides into two parts:
• Upper branch from which are given off the temporal, zygomatic
and upper buccal branches
• Lower branch from which arise the lower buccal, mandibular
and cervical branches

31. PAROTID GLAND cont…d
DUCT OF PAROTID GLAND (Stensen’s duct)
Beginning: The duct emerges from the anterior border of the gland.
Length: It is about 5 cm long.
Course:
• Passes forwards across the masseter muscle.
• Curves medially at the anterior border of the masseter to pierce
the buccinator muscle and the mucous membrane of the cheek.
• Open into the vestibule of the mouth cavity opposite to the
second upper molar tooth.

35. PAROTID GLAND cont…d
SURGICAL LANDMARK OF FACIAL NERVE
• Tragal cartilage pointer:
Facial nerve is 1 - 1.5 cm medial and
inferior to tragal point.
• Tympanomastoid suture:
Facial nerve lies 6–8 mm deep to the
suture. (Most constant landmark)

36. PAROTID GLAND cont…d
SURGICAL LANDMARK OF FACIAL NERVE
• Posterior belly of digastric: Follow the posterior belly of digastric up
to 5 mm below the bony meatal edge.
The facial nerve lies between the mastoid and the posterosuperior
part of the posterior belly of digastric muscle.
The facial nerve passes downwards, forwards and laterally
immediately above the upper border of digastric posterior belly.
• Styloid process: Facial nerve lies on the posteriolateral aspect of
the styloid near its base.

39. Coarse of the Facial nerve :

41. PAROTID GLAND cont…d
NERVE SUPPLY
• Pre - ganglionic secretomotor fibres are carried from the inferior
salivary nucleus to the otic ganglion via the glossopharyngeal
nerve, tympanic plexus and lesser petrosal nerve.
• Post -ganglionic fibres are carried to the parotid gland via the
Auriculotemporal nerve.
• Sympathetic supply is from the superior salivary nucleus, carried by
the sympathetic plexus surrounding the carotid vessels.

43. PAROTID GLAND cont…d
VESSELS AND NERVES
Arterial supply: External carotid artery.
Venous drainage: Retromandibular vein.
Efferent innervation: parasympathetic
Tympanic branch of the glossopahryngeal nerve relaying
in the otic ganglion and reaching the gland via the
auriculotemporal nerve.
Sympathetic innervation via the external carotid plexus.
Secretomotor fibres are derived form the chorda tympani

44. SUBMANDIBULAR GLAND
INTRODUCTION
• Irregular in shape and about the size of a walnut.
• Consists of a larger superficial part and smaller deep part wrapped
around the posterior border of mylohyoid.
• Covered by deep cervical fascia.
• Superficial layer is attached to the base of mandible.
• Deep layer is attached to mylohyoid line of the mandible.
• 3 surfaces: inferior, lateral, medial.

48. SUBMANDIBULAR GLAND cont…d
INFERIOR SURFACE
Its covered by:
1. Skin
2. Platysma
3. Deep cervical facsia
4. Related to the cervical branch of the facial nerve

50. LATERAL SURFACE
• Adjacent to the submandibular fossa on the mandible.
• Facial artery enters posteriorly and emerges between the gland and
the lower border of mandible.

51. SUBMANDIBULAR GLAND cont…d
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,
Wall of pharynx.

53. SUBMANDIBULAR GLAND cont…d
DEEP PART
• Lies deep to the mylohyoid and superficial to hyoglossus and
styloglossus
• Posteriorly, continuous with superficial part around the posterior
border of mylohyoid.

54. SUBMANDIBULAR GLAND cont…d
MAIN EXCRETORY DUCT
Wharton’s duct.
Length = 5cms.
• It emerges at the anterior end of the deep part of the gland.
• Runs forwards on the hyoglossus between lingual and hypoglossal
nerve.
• At the anterior border of hyoglossus it is crossed by lingual nerve.
• Opens in the floor of mouth at the side of frenulum of tongue.

57. SUBMANDIBULAR GLAND cont…d
NERVE SUPPLY
•Parasympathetic fibres from the chorda tympani
•Sensory fibres form the lingual branch of mandibular nerve
•Sympathetic fibres from the plexus on facial artery.

59. SUBMANDIBULAR GLAND cont…d
ARTERIAL AND VENOUS SUPPLY
Artery: Branches of facial and lingual arteries.
Veins: Drains into corresponding veins
Lymphatics: Deep cervical nodes via submandibular nodes

60. SUBLINGUAL GLAND
• Is the smallest of the paired salivary glands.
• Almond shaped.
• Lie beneath the mucosa of the floor of the mouth.
• Posteriorly, close to the deep part of the submandibular gland.
• Medially, separated from the genioglossus by the lingual nerve and
submandibular duct.

61. SUBLINGUAL GLAND cont…d
SUBLINGUAL DUCT
• Major duct is called as the Bartholin’s duct.
• 8-20 minor ducts called as the Ducts of Rivinus.
• Most of them open directly into the floor of the mouth
• Few of them join the submandibular duct.

63. SUBLINGUAL GLAND cont…d
VESSELS AND NERVES
Blood supply: sublingual and submental vessels.
Nerve supply: by the chorda tympani, lingual nerve,
sympathetic plexus.

64. MINOR SALIVARY GLAND
• There are about 450 minor salivary glands in situated in the mucosa
of lips, cheeks, floor of mouth and retromolar region.
• 250 on hard palate,
• 100 on soft palate and 10 on uvula,
• The minor salivary glands also occur in the other areas of the
sinuses, oropharynx, larynx and trachea.
• Contributes 10% of the total salivary volume

66. Superficial Parotidectomy
Goal of surgery : Identification and dissection of facial nerve and
Subsequent resection of parotid lesion.
Important Anatomical area : Superficial Muscular Aponeurotic system
Facial Nerve
Superficial Muscular Aponeurotic system : It refers to fibrofatty layer enclosing facial
muscles.
In lower face, branches of facial nerve pass deep to both SMAS and Platysma.
Dissection of this area is safest above SMAS and platysma.

67. Facial nerve : single most important structure to dissect in a parotidectomy.
For surgical purpose ,the gland is divided into superficial and deep relative to its
position.
• The facial nerve may be identified in an anterograde or retrograde fashion.
• Anterograde approach is favoured.
The Tympanomastiod suture is palpatory landmark found distal to cartilaginous EAC ,
nerve is located up to 6 mm below it.
The Tragal pointer (of Conley) is a small cap of cartilaginous tissue that extends below
the helix of auricle in a parotid dissection.
Another important marker - Posterior belly of digastric ,origin from mastoid process.
facial nerve identified as 2-3 mm did structure above muscle.

70. • Within parotid gland , within 2 cm, the main trunk divides at the pes anserinus to
give the zygomaticotemporal and cervicofacial trunks.
• These divide within gland to give five final branches: temporal, zygomatic,
buccinator, marginal mandibular and cervical nerves.

71. • Retrograde dissection: a line drawn from approximately 1 cm inferior to tragus to 1.5
cm superolateral to eyebrow called Pitanguy line, approximates the location of
temporal branch of facial nerve.

72. Total parotidectomy
• Surgical removal of the entire parotid gland.
• Indication: Removal of deep lobe benign tumours and
Metastatic malignancy that spreads to intraparotid nodes deep to facial nerve.
• Total parotidectomy can encompass preservation or sacrifice of facial nerve.
• Whenever possible Facial nerves are preserved for future nerve grafting
• A temporal bone resection can also be included, including excision of
temperomandibular joint, mastoid process and EAC.

73. Submandibular gland excision
• Indication: chronic sialadenitis and sialolithiasis & Tumours.
• Important structures encountered: Marginal submandibular branch of facial nerve
Hypoglossal nerve.
Lingual nerve.
Digastric and Mylohyoid muscle.
• Marginal mandibular nerve: location of cervical incision is important to avoid it.
• If facial artery is palpated at anterior body of masseter over ramus of mandible, the
surgeon can be confident that marginal mandibular nerve is superior to inferior
border of mandible while dissecting anterior to this artery.

74. • Posterior to facial artery, position of nerve is variable so transcervical incision given
at least 2 cm below mandible. Measured as two fingers breadths.

75. MCQ’s
1. Otic ganglion supplies:
[NEET pattern 2012]
a. Submandibular gland
b. Lingual gland
c. Parotid gland
d. All three

76. 2. Preganglionic fibres to the submandibular ganglion arise from:
[NEET pattern 2012]
a. Superior salivatory nucleus
b. Inferior salivatory nucleus
c. Nucleus of tractus solitarius
d. Nucleus ambiguous

77. 3. Lobes of submandibular gland are divided by which muscle?
[NEET pattern 2015]
a. Mylohyoid
b. Genioglossus
c. Stylohyoidd.
d. Styloglossus

78. 4. Nerve which loops around submandibular duct?
[NEET pattern 2015]
a. Mandibular nerve
b. Lingual nerve
c. Hypoglossal nerve
d. Recurrent laryngeal nerve

79. 5. Superior salivatory nucleus controls all of the following glands EXCEPT:
[NEET pattern 2017]
a. Lacrimal
b. Palatine
c. Sublingual salivary gland
d. Parotid salivary gland

80. 6. What is the name of this incision given for parotidectomy?
[NEET pattern 2017]
a. Battle incision
b. Modified Blairs incision
c. Maylard incision
d. Cherney incision

81. 7. Which among the following is most common neoplasm of salivary
gland? [NEET 2014, WBPG 2012, AIIMS June 98, 2002, 2008, 2015]
a. Pleomorphic adenoma
b. Adenoid cystic carcinoma
c. Mucoepidermoid carcinoma
d. Mixed tumour

82. 8. Plunging ranula is: [Recent Question 2015 & 2018]
a. Cystic growth of sublingual gland
b. Lymph node
c.A tumor in floor of mouth
d. None

83. 9. Bimanual palpation technique is carried out for ?
a. Submandibular gland
b. Sublingual gland
c. Ranula
d. Cervical lymph nodes

84. 10. Identify the marked structure with arrow in the image ?
a. Tubarical glands
b. Accessory parotid glands
c. Spenoid sinus
d. Ectopic salivary gland

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