PPT on salivary gland tumors and stones

1. DISORDERS OF SALIVARY
GLANDS
Talha Ahmed

2. ANATOMY
Salivary Glands
Major
Parotid
Submandibular
Sublingual
Minor
- 600 to 1000 in
number
- 1-5mm in diameter
- Distributed all over
the oral cavity and
oropharynx
- Not seen over the
Anterior 1/3rd of hard
palate and Gingivae

5. Parotid Gland
• Largest salivary gland
• 2 lobes – Superficial and Deep divided by the
Facial Nerve

6. • 3 surfaces
- Antero medial
- Postero medial
- Lateral
• 3 Borders
- Anterior
- Posterior
- Medial

7. Relations

9. • 80% of gland overlies the masseter and the
mandible
• 20% extends medially through the
stylomandibular tunnel (retromandibular
portion)

10. Parotid Capsule
• The investing layer of deep cervical fascia
splits between the angle of mandible and
mastoid process to enclose the gland.

11. Parotid Duct
• ~ Stensen’s Duct
• 5cm in length, 2-3mm in diameter
• Emerges from the anterior surface of gland
• Lies 1cm below the zygomatic arch

13. Faciovenous plane of Patey
• Surgical Importance
• Divides parotid into two lobes
• Facial nerve is Superficial

15. Facial Nerve VIII
• Intra cranial and Extra cranial course
• Only nerve which has motor, sensory, special
visceral afferent and parasympathetic supply
• Divides the parotid gland – Parotid sandwich
• Pes anserinus (Goose foot)

18. Identification of Facial nerve
1. Conley’s point –
1cm deep and
below the tip of
the inferior
portion of the
cartilaginous
canal
2. Inferomedial to
tragal pointer
3. Lateral to styloid
process
4. Deep to posterior
belly of digastric
5. Hamilton-Bailey
technique

23. Nerve supply
• Parasympathetic – Auriculotemporal nerve
- + causes watery secretion
• Sympathetic – Sympathetic plexus around ECA (which in turn
originates from the superior cervical ganglion)
- + causes scanty, viscous & thick secretion

24. Vascular supply
• Arterial – ECA
• Venous – EJV

26. Submandibular Gland
• J shaped gland located in digastric triangle
• 2 lobes – Superficial & Deep divided by the
mylohyoid muscle
• Submandibular gland duct – Wharton’s Duct –
opens beside the frenulum of tongue along
with the sublingual duct

28. Relations

29. Relations

30. Rule of 2

31. Sublingual Gland
• Located in floor of mouth
• Drains directly into oral
mucosa or via SM gland duct
• 8-20 Ducts of Rivinus
• SL duct of Bartholin
Joins the SM gland duct

32. Saliva
• Daily production of 1-1.5 liters
• Water – 99.2% & Organic compounds like
mucin, amylase, lysozyme, IgA, Amylase
Saliva
Parotid (20%)
Serous
Submandibular
(70%)
Mixed
Sublingual and
Minor (10%)
Mucous

33. Functions
• Swallowing
• Keeps mouth moist
• Solvent for taste buds
• Facilitates speech
• Rinses oral cavity and keeps it clean
• Antibacterial
• Neutralizes gastric acid in regurgitation
• Digestion – Hydrolysis of starch by amylase

34. Salivary Gland Disorders

35. 1. Developmental – Agenesis, Atresia, Aberrancy
2. Inflammatory –
a. Bacterial Sialadenitis – Acute and Chronic
b. Viral Sialadenitis – Mumps, Coxsackie A
c. Post irradiation sialadenitis
3. Obstructive and Traumatic –
a. Sialolithiasis
b. Stenosis & Stricture
4. Cystic – Mucus retention, extravasation, Ranula
5. Autoimmune – Sjogren’s syndrome
6. Functional and Metabolic – Sialorrhoea,
Xerostomia, Cirrhosis, Sialadenosis
7. Neoplastic

36. Sialolithiasis
• 80% in the Submandibular gland
• 80% of them are Radiopaque
• Calcium phosphate/carbonate stones
• Parotid gland (20%)
• Rare in Sublingual gland (1%)
• Usually single stone

37. Submandibular
calculus
80%
incidence
80%
Radiopaque
Seen on
plain X ray
Parotid
Calculus
20%
incidence
Radiolucent
Seen on
Sialogram

38. Submandibular
Calculus
Wharton’s Duct
Parenchyma
Hilus
Obstructed in
Calculi are more common in the Submandibular gland because –
 Viscous nature of secretions
 Mucin content
 Calcium content
 Non dependent drainage
 Stasis
 Hooking of nerve by submandibular duct

39. Untreated
Sialolithiasis
Sialadenitis
Clinical Features
appear

40. Sialadenitis
• Infection and Inflammation of the salivary
glands
• Pathogenesis –
 Retrograde contamination of the salivary
ducts and parenchymal tissues by bacteria
inhabiting the oral cavity (Bacterial ascending
infection)
Stasis of salivary flow through the ducts and
parenchyma promotes inflammation

41. Predilection for
Parotid
• Serous secretions
• Lack IgA, lysozymes which are
protective
SM Gland
• Protected by high level of mucin
• Stasis and viscous nature

42. Etiology

45. Acute Sialadenitis
• Sudden onset of pain, swelling and tenderness in the
region of involved gland
• Dysphagia, trismus
• High grade fever
• Double chin appearance due to oedema
• Opening of duct is inflamed and swollen
• Calculus may be seen

46. Chronic Sialadenitis
• Salivary colic – Pain more during mastication
• Swelling disappears 2 hours post
meal/stimulus (Secretion ↑ during
mastication  Gland size ↑)
• Tender, enlarged gland
• Calculus can be seen and palpated
• Pus ++
• Lingual colic – Referred pain to the tongue
due to irritation of lingual nerve in SM gland
sialadenitis

47. Diagnosis
• History and Examination
• Intraoral X ray – Plain occlusal films
- Effective for Intraductal & radiopaque stones
- Intraglandular, radiolucent and small stones may
be missed
• CBC and ESR
• USG – demonstrate stones
• FNAC – to r/o other pathology
• CT of head and neck – when in doubt

50. Treatment of Sialadenitis
• Symptomatic and supportive care
• Hydration
• Sialagogues
• IV Antibiotics
• Analgesics
• Treatment of underlying cause (Stones)

51. Treatment of Sialolithiasis
Sialolithiasis
Sialolithotomy
Intraoral Route
-Stones palpable thru the mouth
-Visualized on X ray
-No further than 2cm from
punctum
Extra oral route
-Shockwave lithotripsy
-Pneumatic lithotripter
Sialoadenectomy
-Very posterior stones
-Intraglandular stones
-Irreversible parenchymal
damage

52. Stones in duct
removed by
opening it
longitudinally

54. Sialoadenectomy (SM gland)
Approach – Extraoral, incision made 2-4cm
below and parallel to the mandible in the
submandibular triangle
NO raising of flaps – to avoid injury to marginal
mandibular nerve
Facial artery ligated twice
Take care of lingual nerve and hypoglossal
nerve
Mylohoid retracted so as to approach the deep
lobe

56. Complications
• Hemorrhage
• Infection
• Injury to –
a. Marginal mandibular nerve
b. Lingual nerve
c. Hypoglossal nerve
d. Nerve to mylohyoid – anesthesia over
submental skin

57. Parotid Abscess
• As a result of acute bacterial sialadenitis of
parotid gland
• Parotid fascia is thick and tough which
encloses the gland – hence parotid abscess
does not show fluctuation
• S. aureus (commonest), S. viridans, Viral

58. Clinical Features
• Fever, Malaise
• Pain
• Trismus
• Warm, tender, well localized & firm swelling in
the parotid region
• Tender palpable lymph nodes
• Pus/Turbid saliva expressed from stensens
duct

60. Management
• USG of parotid region
• Pus for C/S from stensens opening
• Needle aspiration done to confirm pus
• Sialogram is contraindicated
• Proper hydration, mouth wash, nutrition
• IV antibiotics
• Incision and Drainage under G/A – Blair’s
incision

61. BLAIR’S INCISION

62. Complications
• Laryngeal/Pharyngeal oedema leading to
respiratory distress – may need tracheostomy
and steroids
• Septicaemia
• Rupture into External auditory meatus
Untreated/Improperly treated
parotid abscess
Parotid Fistula

63. Parotid Fistula
Parotid
Fistula
Duct
fistula
Gland
fistula
Parotid
Fistula
Internal
fistula
External
fistula

64. • Duct Fistula
- Following superficial
parotidectomy
- Profuse and persistent
- Surgical treatment -
Duct should be ligated
using non absorbable
suture as far as possible
anteriorly – to allow
normal secretion from
deep lobe
• Gland fistula
- From raw surface of the
gland
- Mild and subsides
- Anticholinergic drugs

65. Causes
• Following superficial parotidectomy
• Following drainage of parotid abscess,
ruptured abscess
• Following biopsy
• Trauma
• Recurrence of malignancy

66. Clinical features and Diagnosis
• Abnormal discharge in the region of parotid
• Increases during mastication
• Tenderness and Induration
• Trismus
 Sialography – Gland/Duct fistula
MR Fistulogram

67. Treatment
• Anticholinergics – hyoscine bromide
• Radiotherapy
• Auriculotemporal nerve (PS secretomotor
supply) is cut
• Newman Seabrock’s procedure
• Total Conservative parotidectomy in failed
cases

68. • Newman Seabrock’s Operation
- Probe passed into parotid duct intraorally and thru the
external opening of fistula
- Dissection over the fistula & duct and fistulectomy done
- Tantalum stent passed into the duct across the severed ends
and duct sutured over it
- Stent removed in 3 weeks

69. Salivary Neoplasms

70. WHO Classification of Salivary
Gland Neoplasms – 2017

72. • 1% of head and neck tumors
• Benign tumors – F>>M
• Malignant tumors – M=F
• Genetic, Eskimos
• Recurrent Infections caused by mumps, EBV
• Radiation (~Mucoepidermoid carcinoma)
• Smoking (~Warthin’s tumor)
• Environment and Diet – Nickel, Cadmium,
Silica, hair dyes, Deficiency of Vitamin A

73. Incidence
80% Parotid
80% Benign
80%
Pleomorphic
Adenoma
80%
Superficial
lobe
15%
Submandibular
50% Benign
95% among
benign are
Pleomorphic
Adenoma
5% Sublingual
and Minor
Glands
10% Benign
Incidence of malignancy is
Inversely proportional to the
size of the gland
- In parotid it is 20%
- In submandibular gland it is
50%
- In sublingual and minor
salivary glands it is 90%

74. Pleomorphic Adenoma
• AKA Mixed Salivary tumor
• Commonest salivary neoplasm
• Most common in Parotid and in the
Superficial lobe
• Biphasic with Epithelial and Stromal
components
• Capsulated tumor but may have Pseudopods
which can extend beyond the main limit of
tumor
• Malignant transformation in long standing
cases (>15 yrs) – Carcinoma ex pleomorphic
adenoma

75. Pathology
• Grossly –
- Cartilages
- Cystic spaces
- Solid tissue
• Microscopically
- Epithelial cells
- Myoepithelial cells
- Mucoid material with
myxomatous changes
- Cartilages

76. Clinical Features of Parotid Neoplasm
• Swelling below, behind and infront of the ear
lobule
• Raised ear lobule
• Painless, smooth, firm, mobile swelling
• Curtain’s sign + - cannot be moved above the
zygomatic bone
• Deviation of uvula and pharyngeal wall towards
midline – Deep lobe tumor
• Facial nerve, masseter, skin, lymph node, recent
increase in size, pain and bone involvement with
restricted joint movements– Malignancy
transformation

78. Warthin’s Tumor
• AKA Adenolymphoma
• AKA Papillary Cystadenoma Lymphomatosum
• 2nd most common Benign tumor
• Does not turn into malignancy
• Occurs only in parotid, usually in the lower
pole of the superficial lobe
• Due to the trapping of the jugular lymph sacs
in parotid during development
• Smoking (8 times risk)
• Bilateral (10% cases)
• Elderly White Males ~ 60 years

79. • Slow growing, painless parotid swelling
• Smooth surface involving the lower pole
• Often Bilateral
Investigations
1. Hot spot on Technitium 99 pertechnetate scan – Due to the high
mitochondrial content - Diagnostic
2. FNAC

80. Mucoepidermoid Carcinoma
• Commonest malignant tumor in parotid
• 2nd common malignant tumor in SM, SL &
minor salivary glands
• Parotid is commonest site, Palate is the
commonest minor salivary gland site
• Radiation commonest etiological factor
• Commonest malignant tumor in childhood

81. • Gross
- Unencapsulated solid
tumor
- Cystic spaces
• Microscopy
- Mucin cell - +ve for PAS,
-ve for diastase
- Epidermoid cell
- Clear cell

82. Clinical Features
• Swelling which is slowly increasing in size
• Hard, nodular
• Involvement of skin, lymph nodes & facial
nerve
• Pain

83. Adenoid Cystic Carcinoma
• AKA Cylindromatous carcinoma
• 2nd most common malignant tumor overall
• Commonest malignant tumor of SM, SL and
minor salivary glands
• Palate commonest site
• Rare in parotid
• High affinity for perineural spread
• Invades periosteum and bone medulla early
• Extensive spread to lungs, liver and bones

84. Clinical Features
• Slow growing
• Facial (LMN palsy) & trigeminal nerve
involvement
• High recurrence rate

86. Management of Salivary gland
Neoplasms

87. Investigations
FNAC
Diagnostic
USG
Vascularity, lymph
node status, echo
texture of gland
CT
Status of deep lobe,
Extension to bone,
skull base, neck
nodes, relation to
ICA
MRI
Perineural spread,
bone marrow
involvement,
Recurrent tumors
Open biopsy is CONTRAINDICATED in parotid tumors due to
1. Injury to facial nerve
2. Seeding and Recurrence
3. Parotid fistula due to injury to the duct

88. Parotidectomy
Superficial
Parotidectomy
Superficial
lobe
Total
Conservative
Parotidectomy
Superficial +
Deep lobe
Extracapsular
Parotidectomy
Criss-cross
incision over
parotid fascia,
tumor
removed with
2-3mm margin
without
rupturing
capsule
Radical
Parotidectomy
Fat + Fascia+
Sup. + Deep
lobe + Facial
nerve +
Masseter +
Pterygoid +
buccinator +
Nodal
dissection
Facial Nerve PRESERVED
Facial Nerve
SACRIFICED

89. Operative Considerations
• Lazy ‘S’ incision/Modified Blair’s incision
• Be wary of the Facial nerve NOT the bleeding
• Flap is reflected just up to the anterior margin
of parotid never beyond
• Removal of parotid by dissecting it away from
the facial nerve using bipolar cautery

91. Indications for
Parotidectomy
• T1, T2, T3 low grade
tumors – total
conservative
parotidectomy
• T4, high grade
tumors – Radical
Parotidectomy
Indications for Facial
nerve sacrifice
• Preoperative
paralysis
• Intraoperative
evidence of gross
invasion
• Nerve stump
checked for negative
margins using frozen
section. If +ve, nerve
sacrificed
• Tumors with affinity
for perineural spread
Indications for
Radiotherapy
• High grade tumors
• Perineural spread
• Vascular invasion
• T3, T4 tumors
• Deep lobe tumor
• Neck nodes +ve
• Recurrent/Refractory
tumors
• Inadequate
clearance
Complications of RT –
1. Osteoradionecrosis of
mandible
2. Xerostomia
3. Mucositis/Skin ulcers
4. Trismus
5. Localized hair loss

92. Complications of Parotidectomy
5 F’s

93. Frey’s Syndrome
• AKA Gustatory sweating/Auriculotemporal
syndrome
• Due to injury to the auriculotemporal nerve
• Where in post-ganglionic parasympathetic fibres
from otic ganglion become united with the
sympathetic fibres from the superior cervial
ganglion (Pseudo synapse)
• Inappropriate regeneration of the damaged
parasympathetic autonomic nerve fibres to the
overlying skin

95. Clinical features
• Flushing, erythema, sweating, pain in the skin
innervated by the auriculotemporal nerve
whenever salivation is stimulated. (Gustatory
sweating)
• Minor’s Starch Iodine test
- Involved skin painted with iodine and dried.
Dried starch applied over this area.
- Blue color appears due to sweating in this
area

96. GUSTATORY SWEATING

97. MINOR’S STARCH
IODINE TEST

99. Jacobson’s Neurectomy
Surgical treatment for
Frey’s Syndrome
- Surgical division of
the tympanic
branch of the
Glossopharyngeal
nerve
- Below the round
window of middle
ear
- Intratympanic
parasympathetic
neurectomy

100. Prevention
• Can be prevented by placing
1. Muscle – SCM
2. Fascial - Temporalis
3. Artificial membranes
Over the parotid bed and underneath the skin

102. LMN Facial Nerve Injury
• Bell’s palsy – Idiopathic

103. Most debilitating
symptom is –
Exposure keratitis

104. Treatment

105. Questions asked in MAHE Exams
• Classification of Salivary gland neoplasms (∞
times!!!)
• Pleomorphic adenoma – Clinical features,
complications, management (13 times)
• Warthin’s tumor (10 times)
• Frey’s Syndrome (10 times)
• Salivary calculus (6 times)
• Facial nerve – anatomy, LMN palsy, clinical
features (6 times)
• Parotidectomy – indications, types,
complications (5 times)

106. • Which among the following is the most
common neoplasm of salivary glands? (NEET
2018, 2020) (PLAB and MLE)
A. Mucoepidermoid carcinoma
B. Adenoid cystic carcinoma
C. Pleomorphic adenoma
D. Warthin’s Tumor
Ans. Pleomorphic Adenoma

107. REMEMBER
• MC neoplasm of salivary glands: Pleomorphic
adenoma
• MC malignant tumour of salivary glands:
Mucoepidermoid carcinoma
• MC neoplasm of salivary glands in children:
Hemangioma
• MC malignant tumour of salivary glands in
children: Mucoepidermoid carcinoma
• MC malignant tumour of minor salivary
glands: Adenoid Cystic carcinoma
• MC tumour with perineural infiltration:
Adenoid Cystic carcinoma

108. • Best diagnostic modality of parotid swelling
is? (PLAB and MLE)
A. FNAC
B. Tru cut Biopsy
C. Excision biopsy
D. Enucleation
Ans. FNAC

109. • A 40 year old female presented with a
progressively increasing swelling in the parotid
region. On oral cavity examination the tonsils
were pushed medially. FNAC was s/o of
pleomorphic adenoma. What is the
appropritate treatment? (INICET 2021)
A. Superficial parotidectomy
B. Radical parotidectomy
C. Enucleation
D. Total conservative parotidectomy
Ans. Total conservative parotidectomy

110. • True statement regarding Warthin’s tumor is?
(Plabable)
A. Common in females
B. Most malignant
C. Hot spot on Tc99 scan
D. Most common tumor of minor salivary gland
Ans. Hot spot on Tc99 scan

111. • Tumor with perineural invasion is? (MLE, NEET
2018)
A. Adenoid cystic carcinoma
B. Acinic cell carcinoma
C. Warthin’s tumor
D. Mucoepidermoid carcinoma
Ans. Adenoid cystic carcinoma

112. • Commonest salivary gland to be afflicted with
stones? (MLE, Plabable)
A. Sublingual
B. Parotid
C. Minor salivary glands
D. Submandibular
Ans. Submandibular

113. • Nerves at risk during removal of submandibular
gland are? (Plabable, INICET 2020)
A. Marginal mandibular branch of facial nerve,
Glossopharyngeal nerve and Spinal accessory
nerve
B. Marginal mandibular branch of facial nerve,
Lingual nerve and hypoglossal nerve
C. Marginal mandibular branch of facial nerve,
Lingual nerve and Spinal accessory nerve
D. Hypoglossal nerve, Lingual nerve and
Glossopharyngeal nerve
Ans. Marginal mandibular branch of facial nerve,
Lingual nerve and hypoglossal nerve

114. • Which of the following is not a landmark for
facial nerve during surgery? (MLE, NEET 2019)
A. Digastric muscle
B. Inferior belly of omohyoid
C. Tragal pointer
D. Retrograde dissection of distal branch
Ans. Inferior belly of omohyoid

115. • Frey’s syndrome is characterised by? (INICET
2020, Plabable)
A. Hyperhidrosis, enophthalmos and miosis
B. Anhidrosis, enophthalmos and miosis
C. Redness and sweating over the
auriculotemporal nerve region during meals
D. Pain over the distribution of the
auriculotemporal nerve during meal
Ans. Redness and sweating over the
auriculotemporal nerve region during meals

116. • Newman and Seabrock’s operation is used
for? (Plabable, MLE)
A. Parotid fistula
B. Recurrent chronic parotitis
C. Parotid calculus
D. Frey’s syndrome
Ans. Parotid fistula

117. Thank you