salivary glands

1. SALIVARY GLANDS 1

3. Applied Anatomy
 Major Salivary Glands
 - Parotid
 - Submandibular
 - Sublingual
 Minor Salivary Glands
 - Palate
 - Buccal mucosa
 - Floor of the mouth
 - Labial mucosa

4. Parotid Glands
 Bilateral, Pyramidal in shape
 Fibrous capsule divides it into Superficial and Deep lobes
..... Inferior tail of the gland
 Lateral to the Masseter , wraps around posterior
mandibular border.
 Posteriorly above posterior belly of the Digastric
 Inferiorly near Sternomastoid muscle.
 Medially close to Retropharyngeal Space.
 Separated from the Submandibular Gland by the
Stylomandibular ligament.
 Duct from anterior ... Crosses the Masseter .. Pierces the
Buccinator muscle... Open via Stenson’s duct opposite
Upper 2nd. Molar tooth.

5. Submandibular Gland
 Mixed, mainly mucous
 Superiorly : Mylohyoid
muscle
 Anteriorly : body of the
mandible
 Inferiorly : Digastric
muscle
 Lies on the Hyoglossus
muscle.
 Covered by skin and
platysma

6. Cont.
 Submandibular gland Duct emerges from the
gland at the post. Border of Mylohyoid
...turns Upwards into Sublingual space ..
Anterior direction close to the lingual nerve at
the 3rd. Molar region.
 Opens viaWharthon’s duct into sublingual
area.

7. Sublingual Gland
 Anterior lingual space on Mylohyoid muscle
surface
 Mainly mucous
 Bartholinson’s duct is the main duct, joins
submandibular duct.

8. Functions of Salivary Glands
 Production of Saliva
Contains: Amylase,electrolytes,vitamins,and
immunoglobulins.
 Mastication
 Digestion
 Deglutition
 Neutralization of acids
 Antibacterial and Antiviral
 Speech , Phonation and Articulation

9. Classification of salivary
glands disorders
 Inflammatory SG diseases.
 Obstructive/traumatic SG diseases.
 Metabolic/hormonal SG diseases.
 Reactive SG diseases.
 Salivary gland tumors.

10. Inflammatory SG diseases:
 Viral sialadenitis: Mumps, Cytomegalovirus,
HIV-associated SGD.
 Bacterial sialadenitis: acute sialadenitis and
chronic recurrent sialadenitis.
 Autoimmune SG diseases: Sjogren’s
syndrome.
 Idiopathic: sarcoidosis.
 Radiation-associated sialadenitis.

11. Mumps
 Mumps virus is an RNA paramyxovirus that
primarily affects salivary glands.
 Children 5-9 years, adult may be affect.
 Transmission: salivary droplets, respiratory
droplets, urine.
 Incubation period: 2-4 weeks.

12. Symptoms & sings:
1. 30% are sub-clinical.
2. Prodromal symptoms: low-grade fever,
headache, anorexia, myalgia, & sore throat.
3. A day later: painful unilateral later become
bilateral parotid gland swelling displacing the
earlobe.
4. Pain increases during chewing food.
5. Redness of the opening of the duct.

13. Treatment:
 Palliative (symptomatic) treatment.
 Non-aspirin analgesic.
 Antipyretic.
 Bed rest & rehydration.
 Lifelong immunity.
 Vaccination MMR.

14. CYTOMEGALOVIRUS

15.  It is human herpes virus type 5.
 The virus resides in salivary gland cells.
 Neonates, & immunosuppressed adult.
 Transmission: through placenta, during
delivery, breast feeding, body fluids.

16.  Parotid or submandibular glands enlarged.
 Fever, headache, anorexia, maylgia,
abnormal liver function.

17. Treatment:
 Resolve spontaneously.
 Ganciclovir (immunosuppressed patients).

18. HIV-ASSOCIATED SALIVARY
GLAND DISEASES

19.  5% of HIV-infected patients.
 Parotid gland enlargement, which could be
bilateral.
 Diffuse infiltrative lymphocytosis syndrome.
 Multiple lymphoepithelial cysts in the parotid
glands.
 Increased risk for B-cell lymphoma.
 Xerostomia.

20. Treatment
 Antiretroviral therapy.

21. BACTERIAL SIALADENITIS

22. ACUTE BACTERIAL
SIALADENITIS

23. Etio-pathogenesis:
 Microbiology: Staph. aureus, alpha-hemolytic
strept., or Hemophilus spp.
 A retrograde (ascending) infection.
 Predisposing factor: Decrease salivary flow
(dehydration, drugs etc.).

24. Clinical features:
 Parotid gland.
 Painful firm erythematous swelling of
preauricular & postauricular areas.
 Purulent discharge on milking the gland.
 Low-grade fever, trismus.

25. Diagnosis & treatment:
 Culture for sensitivity.
 Antibiotic (flucloxacillin or erythromycin).
 Drainage of pus.
 Rehydration.
 Sialography, later on to know the
predisposing factor.

26. CHRONIC RECURRENT BACTERIAL
SIALADENITIS

27. Etio-pathogenesis:
 Predisposing factors: ductal obstruction
(salivary stone, congenital stricture), or
Sjogren’s syndrome.
 A retrograde (ascending) infection.
 Microbiology: the same as acute.

28. Clinical features
 Period glandular swelling & pain at mealtime.
 Sialography: ductal dilatation (sialectasia).

29. SJOGREN’S SYNDROME.

30. Definition:
 A chronic systemic autoimmune disease
characterized by acinar destruction of
salivary & lachrymal glands, resulting in dry
mouth & dry eyes.

31. Classification:
 Primary SS: dry mouth & dry eyes.
 Secondary SS: dry mouth, dry eyes, & other
connective tissue disorders (rheumatoid
arthritis or systemic lupus erythematosus).

32. Etio- pathogenesis
 Unknown.
 Increased apoptosis of acinar cells, which
initiated by viruses.
 Co-expression of HLAs (HLA-DRw52, HLA-
B8, and HLA-DR3) activate lymphocytic
infiltration.
 Lymphocytes produce autoantibodies result
in formation of immune complexes.

33. Clinical features:
 Females (80-90%).
 Middle age (40 years).
 Diffuse painless parotid swelling (30-50% of patients),
bilateral.
 Xerostomia:
1. Foamy saliva.
2. Difficulty in swallowing, wearing dentures.
3. Fissured and atrophic tongue.
4. Candidiasis.
5. Cervical caries.
6. Bacterial sialadenitis.

35.  Ocular manifestations: xerophthalmia,
scratchy, gritty sensation, blurred vision.
 Secondary SS other systems & organs are
involved: arthritis, GIT, renal, vascular
pathosis, etc.

36. Treatment
 Supportive.
 Artificial saliva.
 Sugarless chewing gum.
 Sialagogues ( pilocarpine & cevimeline).
 5% may develop lymphoma.
 Strict oral hygiene measures.
 Eyes: artificial tears, sealed glasses.

37. SARCOIDOSIS

38.  It is a multisystem granulomatous disorder
of unknown cause.
 Heerfordt’s syndrome ( uveoparotid fever):
1. Parotid enlargement.
2. Anterior uveitis of the eye.
3. Facial paralysis.
4. Fever.

39. SALIVARY GLANDS 2

40. DISTURBANCES OF SALIVATION

41. XEROSTOMIA

42. PTYALISM/SIALORRHOEA

43. Excessive salivation.
 Causes:
1. Local irritations ( denture, ulcer).
2. Rabies.
3. Heavy metal poisoning.
4. Drugs (lithium, cholinergic agonists).
5. Neurological disorder.
6. GIT reflux disease.

44. OBSTRUCTIVE SG DISEASES

45.  Salivary ductal obstruction usually caused by
salivary stones (sialolithiasis).
 Stones are calcified structures formed around a
an organic nidus.
 Submandibular gland.
 Young and middle age.
 Cause recurrent sialadenitis.
 It may be palpated.
 X-ray: radiopaque mass ( but not all are detected
by x-rays).

46. METABOLIC/HORMONAL SG
DISEASES
Sialosis

47. Sialosis
 Non-inflammatory disorder characterized by
bilateral parotid gland swelling.
 Conditions associated with sialosis:
 Endocrine: diabetes mellitus& insipidus,
Acromegaly, hypothyroidism, pregnancy.
 Nutritional: general, alcoholism, anorexia nervosa,
bulimia.
 Neurological: antihypertensive drugs, psychtropic
drugs, sympathomimetic drugs.

48. REACTIVE SG DISEASES

49. Necrotizing sialometaplasia
 Locally destructive inflammatory salivary
gland condition that resemble clinically and
histologically malignant squamous cell
carcinoma.

50. SALIVARY GLAND TUMORS

51. Classification
 Epithelial tumors:
 Benign (adenoma):
1. Pleomorphic adenoma.
2. Warthin’s tumor ( papillary cystadenoma
lymphomatosum.
3. Basal cell adenoma.
4. Canalicular adenoma.
5. Oncocytoma (oxyphilic adenoma).
6. Ductal papilloma.

52.  Malignant (carcinomas):
1. Mucoepidermoid carcinoma.
2. Adenoid cystic carcinoma.
3. Acinic cell carcinoma.
4. Polymorphous low grade adenocarcinoma.
5. Carcinoma in pleomorphic adenoma.
6. Adenocarcinoma.
7. Squamous cell carcinoma.
8. Undifferentiated carcinomas.

53.  Non-epithelial tumors:
1. Juvenile hemangioma.
2. Lipoma.
3. Neurolemmoma.
4. Lymphoma.
 Secondary (metastatic) tumors.
 Tumor-like lesions.

54. Incidence
 Annual incidence around the world ranges from1-
6.5 per 100,000 people.
 Higher incidence is noticed in Eskimos.
 Parotid gland is the most common site (64-80%).
 Pleomorphic adenoma is the most common
neoplasm.
 Mucoepidermoid carcinoma is the most common
malignant tumor.
 In great Britain the malignant mixed tumor is the
most common malignant tumor.

55. PLEOMORPHIC ADENOMA (BENIGN
MIXED TUMOR)
 The pleomorphic adenoma, or benign
mixed tumor is the most common salivary
neoplasm. It accounts for 53% to 77% of
parotid tumors, 44% to 68% of
submandibular tumors, and 33% to 43% of
minor gland tumors.
 Pleomorphic adenomas are derived from a
mixture of ductal and myoepithelial elements

56. CLINICAL FEATURES
 painless, slowly growing, firm mass
 The tumor can occur at any age but is most
common in young and middle-aged adults
between the ages of 30 and 60.
 also the most common primary salivary gland
tumor to develop during childhood.There is a
slight female predilection

61.  Most pleomorphic adenomas of the parotid
gland occur in the superficial lobe and present
as a swelling overlying the mandibular ramus
in front of the ear.
 Facial nerve palsy and pain are rare
 The palate is the most common site for minor
gland, accounting for approximately 50%
 This is followed by the upper lip (27%) and
buccal mucosa (17%).

62. TREATMENT AND PROGNOSIS
 Pleomorphic adenomas are best treated by
surgical excision. For lesions in the superficial
lobe of the parotid gland, superficial
parotidectomy with identification and
preservation of the facial nerve
 For tumors of the deep lobe of the parotid, total
parotidectomy is usually necessary, also with
preservation of the facial nerve, if possible.
Submandibular tumors are best treated by total
removal of the gland with the tumor.Tumors of
the hard palate usually are excised down to
periosteum, including the overlying mucosa.

63.  With adequate surgery the prognosis is
excellent, with a cure rate of more than 95%.
The risk of recurrence appears to be lower for
tumors of the minor glands.
 The risk of malignant transformation is
 probably small, but it may occur in as many as
5%

64. WARTHIN TUMOR (PAPILLARY
CYSTADENOMA LYMPHOMATOSUM
 Warthin tumor is a benign neoplasm that
occurs almost exclusively in the parotid
gland. Although it is much less common than
the pleomorphic adenoma, it represents the
second most common benign parotid tumor

65. CLINICAL FEATURES
 TheWarthin tumor usually appears as a
slowly growing, painless, nodular mass of the
parotid gland . It may be firm or fluctuant to
palpation.The tumor most frequently occurs
in the tail of the parotid near the angle of the
mandible
 Warthin tumor most often occurs in older
adults, with a peak prevalence in the sixth
and seventh decades of life

67. TREATMENT AND PROGNOSIS
 Surgical removal is the treatment of choice
for patients withWarthin tumor
 Malignant Warthin tumors have been
reported but are exceedingly rare.

68. MUCOEPIDERMOID CARCINOMA
 the most common malignant salivary gland
neoplasm.
 The tumor occurs fairly evenly over a wide age
range, extending from the second to seventh
decades of life. Rarely is it seen in the first decade of
life.
 However, mucoepidermoid carcinoma is the most
common malignant salivary gland tumor in children.
 Some tumors have been associated with a previous
history of radiation therapy to the head and neck
Region.

69. CLINICAL FEATURES
 most common in the parotid gland and usually
appears as an asymptomatic swelling. Most
patients are aware of the lesion for 1 year or less,
although some report a mass of many years’
duration. Pain or facial nerve palsy may develop
 Minor gland tumors also typically appear as
asymptomatic swellings, which are sometimes
fluctuant and have a blue or red color that can be
mistaken clinically for a mucocele

72. TREATMENT AND PROGNOSIS
 Early-stage tumors of the parotid often can
be treated by subtotal parotidectomy with
preservation of the facial nerve. Advanced
tumors may necessitate total removal of the
parotid gland, with sacrifice of the facial
nerve. Submandibular gland tumors are
treated by total removal of the gland.
Mucoepidermoid carcinomas of the minor
glands usually are treated by assured surgical
excision

73. ADENOID CYSTIC CARCINOMA
 The adenoid cystic carcinoma can occur in
any salivary gland site, but approximately
50% to 60% develop within the minor salivary
glands.The palate is the most common site
for minor gland tumors .The remaining
tumors are found mostly in the parotid and
submandibular glands

74. CLINICAL FEATURES
 The adenoid cystic carcinoma usually appears
as a slowly growing mass. Pain is a common
and important finding, occasionally occurring
early in the course of the disease before there
is a noticeable swelling. Patients often
complain of a constant, low-grade, dull ache,
which gradually increases in intensity. Facial
nerve paralysis may develop with parotid
tumors.Palatal tumors can be smooth
surfaced or ulcerated

75. TREATMENT AND PROGNOSIS
 Surgical excision

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