Approach to Salivary Glands Copyright by Oral & Maxillofacial Surgery Department, UDMY

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4.  A larger (80%)
superficial lobe & a
smaller (20%) deep
lobe
 The branches of the
CN VII between these
lobes invested in loose
connective tissue

6. Above: external
auditory meatus ,
TMJ & zygomatic
arch
Inferior: posterior
belly of digastric ,
SCM
Medially: styloid
process and its
muscles
Anterior : extends
3 to 4 mm over the
surface of the
masseter

7.  Lies directly under the skin with a variable amount of subcutaneous
fat
 Encapsulated by a fibrous layer of parotid fascia [a splitting of the
superficial layer of the deep cervical fascia]
 The superficial layer of the parotid capsule is part of the superficial
musculo-aponeurotic system (SMAS)
 The deep layer of the parotid capsule is attached to the mandible
and the temporal bone at the tympanic plate , styloid and mastoid
processes

9. The Facial Nerve
Auriculotemporal Nerve
Retromandibular Vein
External Carotid Artery
Parotid Lymph Nodes
Parotid Duct
Nerve Supply to the Parotid

10. Innervate the facial muscles
on their DEEP side
Except for the buccinator,
levator angularis oris and
mentalis muscle --> lies
superficially

13. 2.1 – 2.5 cm
0.8-3.5 cm

14.  Communicates widely
with the temporofacial
division of the facial nerve
 Further communications
with the temporal and
zygomatic branches loop
around the transverse
facial and superficial
temporal vessels

15.  Union of the superficial temporal &
maxillary veins
 Posterior branch
• Join the posterior auricular vein on the surface of
SCM  external jugular vein
 Anterior branch
• Join the facial vein  common facial vein 
Internal jugular vein
• The division of CN VII 
temporofacial & cervicofacial divisions
• Just behind the retromandibular
vein

17.  Within the subcutaneous tissues overlying the parotid
• Preauricular nodes and also within the substance of the gland
 Typically ten nodes within the substance of the gland
• The majority: superficial lobe and therefore superficial to the plane of
the facial nerve
• Only one or two nodes lie within the deep lobe

19.  Exits from the anterolateral portion of the gland
 Passes beyond the anterior portion of the masseter
muscle parallel with a plane drown from the tragus of the
ear to the midpoint of the upper lip
 Penetrate the buccal fat pad and buccinator muscle [
1.0 cm anterior to the anterior border of the masseter
muscle]
 Opening in the mouth at the level of the maxillary second
molar
 Paralleling to the duct in a superior location are the
transverse facial artery, and the buccal branches of the
facial nerve

20. glandular masseter anterior

21. Transverse facial a.
 parallel to and approximately 1 cm above the parotid duct

22.  The parasympathetic
secretomotor nerve
• From the inferior
salivatory nucleus in
the brain stem
 The sympathetic nerve
supply
• From the superior
cervical sympathetic
ganglion

23.  Superficial lobe parotidectomy
 Total parotidectomy

24. • Indications
 Benign tumours or low-grade malignant tumours of
small size and without involvement of the facial nerve in
the superficial lobe of the parotid gland
 Chronic inflammation of the parotid gland, resistant to
conservative treatment
 Tumour-like lesions in the parotid, such as nodular
Sjögrens syndrome
 Metastases to parotid lymph nodes from adjacent
sites of skin cancer
 Access to the deep lobe of the gland or other
structures deep to the facial nerve

25.  General anesthesia
 Muscle paralysis/ Long-term paralytic
agents are avoided to allow for facial nerve
monitoring +/- EMG
 Draped patient  exposed entire side of
face
 Anesthesia
 Modified Blair incision

26. • Local anaesthesia with 1% Lidocaine (containing
adrenaline if possible) is satisfactory
• Subcutaneous injection of the anaesthetic is
administered over the whole operative field
• After elevation of the skin flap, anaesthetic is
injected into the superficial gland before the gland
is incised

27. Ant.& Sup. to tragus 
Skin crease down to ear
lobe 
Extended around ear
lobe to postauricular
area 
Curvilinear to natural
skin crease in
submandibular area

30.  To expose the gland, skin flaps
are elevated
• preauricular region : superficial
to the parotid fascia
• cervical portion : subplatysmal
plane
 Identify the great auricular nerve
and the external jugular vein [over
the SCM]
 Then free parotid tail, SCM &
mastoid tip
 Exposed the posterior belly of
digastric muscle

34. Incising the SCM-parotid fascia along
antero-medial edge of SCM
Utilizing blunt & sharp dissection to further
immobilization the tail
Alice clamping to identifing digastric m.
** facial n. exits the stylomastoid foramen on
a plane/just above attachment of digastric
muscle to digastric groove of the mastoid
tip

35.  To open a plane
•  parallel to facial n.
•  from zygoma (sup.) to just above
styloid process (inf.)

36.  Pretragal & Tail immobilized
 “Narrow bridge” of parotid
tissue & fascia attached to
mastoid tip

37. • Tympanomastoid suture
 nerve is usually 6 -8 mm below to the end of this suture
• Digastric muscle
 nerve is immediately superior to digastric
• Tragal pointer :
 1 cm anterior and inferior,
 1 cm deep to the tragal pointer
 This relationship may be altered by the presence of
tumor, previous surgery, or infection


40. “Slide, lift, spread & cut technique” in
Horizontal plane parallel to nerve

41.  Wound irrigation
 Haemostasis
 0.5 mA stimulated main trunk
 Microsurgical repair if indicated
 Wound closure

43. Indications
• Tumor of the deep lobe
• Recurrent pleomorphic adenoma
• Malignant tumours
• Recurrent severe supperative parotitis secondary
to calculi/ ductal stenosis

45.  Facial nerve paralysis
 Sensory abnormalities associated with sacrifice
of the great auricular nerve
 Salivary fistula
 Gustatory sweating : Frey’s syndrome
• Flushing and sweating of the ipsilateral facial skin
during mastication

47.  Lies in the submandibular
triangle
 Superior : medial and inferior
to the ramus
 Inferior : the base of the
posterior half of the mandible
Forms a ‘C’ around the
anterior margin of the
mylohyoid muscle
 This muscle divides the gland
into superficial and deep lobe

48. • Exits the medial surface of the gland
• Open lateral to the lingual frenulum on
the anterior floor of mouth intraorally
• Averages 5 cm in length
• Lingual nerve wraps around the duct,
starting lateral and ending medial to
the duct
• Arises from the superior portion of the
gland with a vertical, upward, slanting
course, curving sharply at the posterior
border of the mylohyoid muscle

49. Wharton’s duct
• Hypoglassal nerve runs parallel to this duct, just
inferior to it

50. • Supply motor fibers to
the facial muscles in the
lower lip and chin
• The farthest distance
between a marginal
mandibular branch and
the inferior border of
mandible was 1.2 cm
• Lies underneath the
superficial layer of deep
cervical fascia

52.  The smallest of the major salivary glands
 Lies just deep to the floor of mouth mucosa between the
mandible and Genioglossus muscle
• It is drained by
approximately 10 small ducts
(the Ducts of Rivinus)
• Occasionally, several of the
ducts may join to form a
common duct (Bartholin’s
duct), which typically empties
into Wharton’s duct.

53.  Mucus-retention phenomenon [mucocele]
• Most often on the lower lip
• Results from an extravasation of fluid into the
surrounding tissue after traumatic break in the
continuity of the ducts
• Best treated by surgical removal
• Elliptic excision and removal of the cystic area and
associated minor salivary glands

54.  Ranula
• 2 varieties
• Simple ranulas : true retention cysts of the sublingual
glands
• Plunging ranulas : a cyst that extends beyond the
mucous membranes of the oral cavity into the floor of
mouth, through a hiatus of mylohyoid muscle, and into
the fascial planes of the neck
Simple ranulas
Plunging ranulas

55.  2 accepted machanisms for formation
• Partial obstruction of the distal end of the duct with
dilation resulting in an epithelial lined cyst
• Disruption of the duct with formation of a CNT lined
space
 The source of the cyst fluid is believed to be
sublingual glands

56. Excision of the sublingual gland
• Making a linear incision along the superior aspect,
medial to the plica sublingularis
• A probe is inserted in
the submandibular duct
during the dissection to
aid in its identification and
preservation

57.  Identify the submandibular duct and lingual nerve first

58. The gland is elevated and freed from its contact with the
wharton’s duct and branches of the lingual nerve
with blunt dissection

59.  Anterolateral aspect of the gland may
be attached to the periosteum of the
mandible
 Several branches of the sublingual
artery may have to be clamped and
ligated

60.  Coaptation of the mucosal edges of the incision.
 The catheter in wharton’s duct is removed.

61. May be found at 4 basic sites
• Impacted at the papilla
• In the submucous part of the duct
• Extraglandular part of the duct external to the
buccinator muscle
• Intraglandular part of the duct

62. Calculi can be released by slitting the
papilla
• One blade of a pair of fine, sharp-pointed scissors
is inserted
• A short cut is made backward from the orifice
• Or … Gentle pressure on the gland will force a
quantity of the saliva, washing out the calculus

63.  Local anesthetic with vasoconstrictor
 Y-incision is made, and the tip of the triangle,
containing the papilla and duct, is raised from the
surface of the buccinator muscle with blunt
dissection

64.  Dissection is directed laterally into the cheek and
posterior to the point where the duct pierces the
buccinator muscle
 The buccal fat pad can be seen, lateral, posterior and
superior to the duct
 Then the buccinator dehiscence is identified
 And the traction sutures are placed through each margin
 Enlarges the dehiscence
 Tracing the duct
 Once the calculus is found : a linear incision parallel to
the long axis of the duct is made, and the stone is
removed

65. Approach to these stones is similar to that
use for removal of parotid gland

66.  Anterior portion of the
submandibular duct
• A suture is passed into the
floor of the mouth around
the duct, posterior to the
stone
• A second suture is placed
between the duct papilla
and the frenum
• Incision is made along the
line of the duct and over
the stone
• A few interrupted sutures
in the FOM to approximate
the membrane

67. Posterior portion of the duct
• Best to do under GA
• A lacrimal probe can be inserted in the ductal
orifice
• Then elevated to locate the duct
• The mucosa is excised in the area opposite the
premolar tooth
• Once the duct is found, then pass the suture
material around
• It will be possible to locate the lingual nerve

68. Posterior portion of the duct
• Enlarge the initial incision
• The duct emerges from the upper and anterior
part of the upper pole of the gland
• Another suture is placed near the posterior margin
of mylohyoid muscle to retract it forward
• Identify the calculus, then the incision will be done
parallelly to the long axis of the duct

69. Posterior portion of the duct
• Remove the traction sutures
• The incised duct is left open
• And the mucosal tissues are closed with
interrupted sutures

70. Intraglandular portion
• The entire gland is recommended to remove.
• If the gland is asymptomatic, the stone may be left
in place and observed

71.  A 2-inch-long convex incision parallel to the skin
crease, approximately 1.5-2 cm below the inferior
border of the mandible
 The initial incision is carried through the skin and
subcutaneous tissues to the level of the platysma
muscle

72.  Sharp dissection through
the platysma muscle
 The superficial layer of
deep cervical fascia
overlying the
submandibular gland

73.  Marginal mandibular branch of CN VII lies
immediately beneath the superficial layer of
deep cervical fascia

74.  Anterior facial vein is ligated and transected
below the nerve, and upward retraction
 [the nerve will be displaced superiorly]

75.  Superior dissection proceeds by double ligation
and transection of the facial artery, which free
the superior attachment of the gland

76.  Anteriorly, the vessels to the mylohyoid muscle
are divided
 The gland is mobilized posteriorly exposed the
free edge of mylohyoid muscle
 Mylohyoid is retracted anteriorly and the gland
posteriorly

77.  Exposes the lingual nerve, submandibular
ganglion, and wharton’s duct, and hypoglossal
nerve
 They lie superficial to hyoglossus muscle

78.  The contribution of the lingual nerve to the
submandibular ganglion is transected
 And the wharton’s duct is doubly ligated and
divided

79.  Deep portion of the gland can be delivered
 Finally, the facial artery is divided a second time,
and the gland is removed

111.  On average about 0.5 liters of saliva are
produced each day but the rate varies
throughout the day.
 At rest, about 0.3 ml/min are produced, but
this rises to 2.0 ml/min with stimulation
 At rest, the parotid produces 20%, the
submandibular gland 65%, and the sublingual
and minor glands 15%. On stimulation, the
parotid secretion rises to 50%