This document discusses diseases of the salivary glands, focusing on inflammatory disorders of the parotid gland. It describes various causes of parotid inflammation including viral infections like mumps, bacterial infections, HIV-associated sialadenitis, and obstructive disorders. It also discusses benign conditions such as sialadenosis and Sjogren's syndrome. The document outlines the indications for and steps of parotid surgery including superficial parotidectomy, total parotidectomy, and radical parotidectomy. Post-surgical complications like Frey's syndrome are also mentioned.

1. DISEASES OF THE SALIVARY GLANDS
GIRISH KUMAR N M
ASSISTANT PROFESSOR
DEPT OF SURGERY

2. CONTENTS
• SLO’S ADRESSED :
1. INFLAMMATORY DISEASES OF THE PAROTID GLAND.
2. INDICATIONS AND STEPS OF PAROTIDECTOMY
3. COMPLICATIONS OF PAROTID GLAND SURGERY

3. INFLAMMATORY DISORDERS OF THE
PAROTID GLAND(SIALADENITIS)

4. VIRAL INFECTIONS:
• MUMPS, IS THE MOST COMMONLY FOUND VIRAL
INFECTION, AFFECTS CHILDREN.
• AIRBORNE DROPLETS OF INFECTED SALIVA.
• PRODORMAL PERIOD OF 1-2 DAYS, DURING WHICH
PATIENT EXPERIENCES NAUSEA, FEVER, HEADACHE.
• FOLLOWED BY PAIN AND SWELLING IN ONE OR BOTH
PAROTIDS.
• PAIN EXACERBATES WITH DRINKING OR EATING.
SYMPTOMS RESOLVE WITHIN 5-10 DAYS.

5. • DIAGNOSIS BASED ON HISTORY AND CLINICAL EXAMINATION.
• SINGLE EPISODE CONFERS LIFELONG IMMUNITY.
• TREATMENT IS SYMPTOMATIC.
• COMPLICATIONS ARE OOPHORITIS, ORCHITIS, PANCREATITIS,
SNHL, MENINGOENCEPHALITIS.
• OTHER VIRUSES: COXSACKIE A AND B, PARAINFLUENZA 1 AND 3,
ECHO AND LYMPHOCYTIC CHORIOMENINGITIS

6. BACTERIAL INFECTIONS
• ACUTE ASCENDING BACTERIAL SIALADENITIS IS DESCRIBED HISTORICALLY AS ELDERLY
DEHYDRATED PATIENTS.
• MORE COMMON PICTURE IS SECONDARY TO SALIVARY CALCULUS, DUE TO WHICH
SALIVARY FLOW IS REDUCED AND STASIS LEADS TO, SECONDARY BACTERIAL
INFECTION.
• PRESENTS WITH PAINFUL TENDER SWELLING OF THE AFFECTED PAROTID, ARISING
OVER SEVERAL HOURS.
• GENERALISED MALAISE, PYREXIA AND OCCASIONAL CERVICAL LYMPHADENOPATHY.
• SWELLING LOCALISED TO LOWER POLE OF THE GLAND.
• INTRA ORAL EXAMINATION REVEALS PUS EXUDING FROM THE PAROTID GLAND
PAPILLA.
• ORGANISM: STAPH AUREUS OR STREP. VIRIDANS.
• APPROPRIATE IV ANTIBIOTICS, LARGE BORE NEEDLE OR FORMAL DRAINAGE UNDER
GA (HILTON’S METHOD)

8. HIV ASSOCIATED SIALADENITIS
• prevalence is between 5% and 10%
• mainly characterised by bilateral enlargement of the parotid glands
• mimic SjS
• young individuals with an absence of any serological antibodies
• more common in women on highly active antiretroviral therapy (HAART)
• Biopsy reveals perivascular, periductal and periacinar areas predominantly infltrated
with CD8 cells.
• Abnormal deposition of fat seen in the parotid gland (parotid lipomatosis)

9. BENIGN LYMPHOEPITHELIAL CYSTS
• are HIV-related reactive lymphoproliferation, which may occur in the intraparotid
lymph nodes.
• parotid glandular epithelium may get trapped within the normal intraparotid lymph
nodes
• migration of HIV-infected cells into the parotid gland, which could trigger lymphoid
proliferation, salivary duct dysplasia, ductal obstruction and cyst formation
• CT AND MRI – Swiss cheese appearance
• Usually regresses on ART therapy
• Aspiration can be done.

11. OBSTRUCTIVE PAROTITIS
CAN BE DIVIDED AS
STONE FORMATION PAPILLARY OBSTRUCTION

12. STONE FORMATION
• LESS COMMON THAN SUBMANDIBULAR GLAND
• RADIOLUCENT, BARELY VISIBLE
• MOST COMMONLY FOUND AT THE REGION CAUSING DUCT
CROSSING OVER THE MASSETTER MUSCLE.
• SMALL STONES- DORMIA BASKET- UPTO 4MM
• LARGER STONES, BROKEN BY LITHOTRIPSY, ENDOSCOPIC ASSISTED
RETRIEVAL

13. PAPILLARY OBSTRUCTION
• OBSTRUCTION, CAN BE CAUSED BY REPEATED TRAUMA TO
PAROTID PAPILLA
• SUBSEQUENT EDEMA AND OBSTRUCTS SALIVARY FLOW, EVEN AT
MEALTIMES
• PARTIAL OBSTRUCTION OVER A PROTRACTED PERIOD LEADS TO
DILATION OF THE DUCT, AN ENTITY KNOWN AS MEGA DUCT
• DRAINAGE OF DUCT IS TO BE ESTABLISHED
• REPEATED AND PROGRESSIVE DILATION OF PUNCTUM WITH
POSSIBLE STENT INSERTION
• PAPILLOTOMY

14. SIALADENOSIS
• Principal regulation of major salivary gland function is via
the autonomic nervous system.
• Dysregulation of autonomic control may lead to a benign
form of salivary gland enlargement called sialadenosis.
• Various conditions that could dysregulate the autonomic
control include obesity, starvation, anorexia nervosa,
bulimia, starch ingestion, alcoholism, diabetes mellitus,
celiac and liver disease, acromegaly, catecholamine
excess, and heavy metal intoxication.

15. • Clinically, sialadenosis presents as painless,
recurrent, bilateral swelling of the parotid glands.
• The peak incidence is in the fifth and sixth decades.
• The clinical differential diagnosis includes other
causes of bilateral salivary gland enlargement, such
as sarcoidosis, Sjögren’s syndrome, tuberculosis,
malignant lymphoma, sialadenitis, gout, and
Graves’ disease.

16. SJOGREN’S SYNDROME
• Sjogren's syndrome (SS) is an autoimmune disease
characterized by the progressive lymphocytic infiltration
and destruction of exocrine glands, particularly the
salivary and lacrimal glands.
• The disease occurs in primary and secondary forms.
• Primary Sjogren's syndrome refers to the occurrence of
xerostomia and xerophthalmia in the absence of another
connective tissue disease and this was previously referred
to as Mikulicz’s disease or sicca syndrome.

17. • Secondary Sjogren's syndrome occurs in association with another
connective tissue disease, such as rheumatoid arthritis, systemic
lupus erythematosus, scleroderma, polymyositis, or polyarteritis.
• The characteristic symptoms are xerostomia and xerophthalmia,
due to destruction of glandular epithelium with resultant
decreased saliva and tear production.

19. CLINICAL FEATURES OF SJOGREN’S SYNDROME
• Sjogren's syndrome is most commonly encountered in post-
menopausal women and up to 90% of patients with SS are
females.
• The average age at diagnosis is 50 years; and is uncommon in
patients under the age of 20.
• Among the major glands, the parotid gland is involved in 85% of
cases and the remaining affect the submandibular gland and rarely
the sublingual glands.
• .

20. • The principal clinical symptoms are due to dryness of the eyes and
mouth, resulting in keratoconjunctivitis and difficulty with
speaking and swallowing of food.
• Many patients present with firm, diffuse enlargement of the
salivary glands, which is usually but not always bilateral.
• Induration of the glands without enlargement may be evident
early in the course of the disease. These changes are usually
painless or associated with slight tenderness

21. • PATIENTS WITH SS HAVE ALMOST 40 TIMES HIGHER RISK FOR
DEVELOPING NON-HODGKIN’S LYMPHOMA.
THE DEVELOPING MALIGNANCY IS USUALLY A LOW-GRADE,
MONOCYTOID B-CELL LYMPHOMA.

22. PAROTIDECTOMY

23. INDICATIONS OF PAROTIDECTOMY
• Tumors are the most common indication or surgical exploration o the parotid
gland.
• Most are benign mixed tumors that arise in the lateral lobe and are treated
with wide excision, including a margin o normal tissue to prevent local
recurrence.
• Exploration of the parotid area must include careful identification of the facial
nerve and its branches, thus avoiding the major complication of facial nerve
palsy.
• Malignant tumors are also seen and require a wide excision, which may
include all or a portion of the facial nerve if, it is involved.
• Lesions of the medial lobe may necessitate a total parotidectomy; a
superficial parotidectomy is carried out first to identify and preserve the facial
nerve be ore the medial lobe is explored.

24. PAROTIDECTOMY
Superficial parotidectomy:
It is the removal of superficial lobe of the parotid
(superficial to facial nerve). Done in case of benign diseases
of superficial lobe of the parotid.

25. Lazy ‘S’ incision—modified Blair's/Sistrunk's approach
and raising the skin flaps
Mobilisation of the gland
Flap is reflected in front just up to anterior margin of
the parotid; never beyond. After identification of
sternocleidomastoid, great auricular nerve is identified
and can be sacrificed. Posterior belly of digastric is
identified.
Location of stylomastoid branch of posterior auricular
artery is anterior to facial nerve trunk which enters the
stylomastoid foramen.
Thrust the mosquito haemostat 5 mm in front of facial
nerve; open the blades for 5 mm; lift the blades for 5
mm.
One should worry about the nerve not small bleeding
and haemostasis.
Identification of facial nerve trunk
Dissection of the gland off the facial nerve using bipolar
cautery
Removal of parotid—superficial/both
Distilled water (hypertonic) irrigation to kill spilled

27. • Total conservative parotidectomy: It is done in benign
diseases of parotid involving either only deep lobe or both
superficial and deep lobes.
• Here both lobes are removed with preservation of facial
nerve. Here initially superficial parotidectomy is done and
facial nerve and its branches are retracted gently and
deep lobe is removed.

28. • Radical parotidectomy: Both lobes of parotid are removed
along with facial nerve, fat, fascia, muscles (masseter,
pterygoids and buccinator), lymph nodes.
• It is done in case of carcinoma parotid.
• Later facial nerve reconstruction is done using great auricular
nerve graft.
• Conservative surgeries are becoming popular for malignancy
but they are not universally accepted.

29. • Supra-facial parotidectomy is done in lower pole parotid
tumors wherein all branches of the facial nerve need not
be dissected.

36. FREY’S SYNDROME PATHWAY
• glossopharyngeal nerve (cranial nerve IX) carries preganglionic parasympathetic fbres
from the inferior salivatory nucleus
• Jacobson nerve, a branch of cranialnerve IX, enters via the inferior tympanic canaliculus
to form the tympanic plexus.
• The lesser petrosal nerve carrying the preganglionic fbres from here exits via the
foramen ovale, where it synapses with the postganglionic secretomotor parasympathetic
fbres in the otic ganglion
• fbres exit the otic ganglion and join the auriculotemporal nerve in the infratemporal
fossa, which innervates the parotid gland for the secretion of saliva

38. THANK YOU