Both the major and the minor salivary glands develop as buds of oral ectoderm. The epithelial bud proliferates into the adjacent mesenchyme, enlarging at its most distal end to form alveoli, with the epithelial cords becoming hollow to form ducts.The epithelial buds that form the parotid and submandibular glands appear during the sixth week of embryonic life, and those for the sublingual glands appear during the seventh to eighth week. The major salivary glands are subject to many anomalies.Accessory glands and glands ectopically placed within the body of the mandible have been noted. Also in the vicinity of a line running from the ear by way of the parathyroid to inner end of the clavicle. Major salivary ducts may be congenitally atretic or, rarely, imperforale.Small lymph nodes are normally found within the confines of the parotid glands, usually near its surface, but not in the submandibular or sublingual glands. Approximately 5 to 10 of these nodes are usually present, having salivary ducts and often some acini in their medullary regions, otherwise they resemble normal lymph nodes. Sebaceous glands, unassociated with hair follicles, are sometimes found in the mucosa of the cheek. The presence of occasional typical sebaceous glands in the parotid gland has been reported.There are four main salivary glands-two submandibular glands and two parotids. There are 300-400 minor salivary glands occurring elsewhere in the upper respiratory tract especially in the hard palate and lateral pharyngeal wall. The minor salivary glands are mucuo-secreting glands situated throughout the upper respiratory tract. There are about 250 glands on the hard palate, 100 on the soft palate and 10 on the uvula.Other glands are found in the submucosa of the inner surface of the lips, around the opening of the parotid duct, in the mucous membrane of the cheek, in the floor of the mouth, in the palatoglossal folds, on the inferior surface of the tongue, near the frenulum and within the palatine tonsilAbout 1500 ml of saliva is secreted per day. pH is slightly less than 7.0 but during active secretion, it 8.0. Saliva contains two digestive enzymes: lingual lipase, secreted by glands on the tongue, and salivary a-amylase secreted by the salivary glands.Saliva also contains mucins, glycoproteins that lubricate the food and protect the oral mucosa. It also contains IgA, the first immunologic defense against bacteria and viruses; lysozym.es, which attacks the walls of bacteria; lactoferrinwhich binds iron arid is bacteriostatic; and proline-rich proteins that protect tooth enamel and bind toxic tannins.Etiology. Clinical Picture: It usually affects children, incubation period is 3 weeks, It starts unilateral but in a few days it affects the other side, Preceded by a prodromal influenza-like syndrome. It causes fever & painful swelling which is soft & tender. There is difficulty in mastication. It never suppurates. It may b

1. Removal of the parotid lateral to the facial
nerve
Indications:
1- Benign and low – grade malignant
parotid neoplasma.
2- Recurrent parotid sialadenitis or
sialolithiasis.
3- Removal of parotid lymph in an area of
suspected or known metastasis.

2. 1-Treatment of moderate of high grade
parotid gland neoplasma.
2- Benign parotid gland neoplasma
located in the inferior – most portion of
the parotid gland with only a narrow
glandular connection.

3. 1- Use of a facial nerve stimulator is
unnecessary except in reoperations.
2-Reoperating in the parotid bed should
with the aid of intraperative faical nerve
monitoring.
3- Key landmarks for identifying the
facial nerve include the cartilaginous
pointer, the mastiod tip, and the
posterior belly of the digstric muscle.

4. 4- tympanomastoid suture line is generally
not a helpful landmark for identiying the
facial nerve.
5- be prepared to perform a retrograde
parotidectomy if the tumour position
prevents safe isolation of the main trunk of
the facial nerve.
6- postauricular artery of is brabches crosses
the main trunk of the facial nerve and can
be a soutce of sigificant bleeding if it is not
properly identified and can be a source of
the main trunk of the facial nerve

5. 7- Observation by an assistant and
notation of facial switching and motion
and its location generlly are more helpful
than the use of a facial nerve stimulator.
8- Aciod making the posterior portion of
the flap in the infraauricular area too thin
or too long to prevent skin necrosis.
9- infection after parotidectomy is rare:
preoperatively, anitibiotics are only
needed with a pre-existing history of
sialadenitis.

6. Removal of the parotid gland deep to the
level of the facial nerve
Indications
1- Benign and malignant deep – lobe parotid
tumours.
2- Removal of the deep portotid gland for
moderated and highgrade malignancies found
in the superfical portion of the parotid gland

7. 3- Chronic sialadenitis.
4- Dumbbell- shaped deep lobe
parapharyngeal and parotid tumours.
Contraindications:
1- Bleeding disorder.
2- Failure to obtain preoperative
computedf tomography or magnetic
resonance imaging studies.

8. Special considerations:
1. In most cases, a superficial
parotidectomy is done first.
2. Unless there is direct invasion of
proximity of a high-grade tumour
to the facial nerve , the facial nerve
can be preserved in most cases of
malignanr disease

9. 3. The extent of tissue that
comprise the deep lobe of the
parotid galnd varies greatly
among individuals.
4. The possibility of performing a
neck dissection should be
discussed with the patient
preoperatively.

10. 5. Frozen-section pathologic
examination should be
available.
6. Deep-lobe tumours can displace
the facial nerve considerable,
altering the typical position and
appearance of the nerve.

11. Tips and pearls:
1. Key to the total removal of the deeo
lobe of the parotid gland is
identification and isolation of the
main regional vessels.
2. For malignant parotid neoplasma,
removal of te deep lobe of the
parotid gland also removes the
nodes found in the deep lobe and
parapharyngeal regions.

12. 3. Many deep-lobe benign
neoplasma may not require the
complete removal of the parotid
deep lobe.

13. 4. For parapharyngeal extension fo
the deep-lobe parotid tumours, key
point in safe removal without
tumour rupture include
identification of the upper neck
vessels and nerves, division of the
stylomandibular ligament,
retraction of the mandible. And
identification of retraction of te
facial nerve.

14. 5. A deep-lobe parotid tumour is
often removed beneath, abovem
or between the nranches of the
fical nerve.
6. It may be helpful to remove the
styloid process if a deep-lobe
tumour extends around the
structure.

15. Pitfalls and complications:
1. Modifications of the facial nerve
generally causes temporary paresis,
especially in the elderly: eye protection
postoperatiely is important.
2. Loss of superficial of deep portions of
the parotid glands or of the compete
gland can cause a cosmetic eformity,
especially if the regional musclature id
removed: reconstruction with a
gracilis free flap should be considered.

16. 3. Bleeding haemoatoma , and airway
compromise can occur, meticulous
hemostasis and hemovac drainage
are important.
4. The surgeon should be aware of the
possibility of a tortuous loop in the
internal carotid artery, extending
within the musculature of the bed
of the parotid gland.

17. Removal of selected benign salivary gland
neoplasma using a transoral approach.
Indications:
1- Benign minor salivary gland
parapharyngeal tumours.
2- Tumour smaller than 5 cms.
3-superior and medial benign parapharyngeal
tumours that are nonvascular non
malignnt , and not parotid in origin.

18. Contraindications
1. Parotid deep-lobe salivary gland
tumours with parapharyngeal
extension.
2. Dumbbell-shaped deep-lobe
parotid tumours.
3. Malignant salivary gland tumours.
4. Parapharyngeal tumours of
intermediate histology

19. 5. Vascular parapharyngeal
tumours.
6. Parapharyngeal tumours with
extension into the crevial
vertebral bodies or base of skull.
7. Bleeding disorder.

20. Special considerations
1. The transoral approach is rarely
used for parapharyngeal tumours.
2. A fat plane must be visible between
the tumour and the deep lobe of the
parotid gland on imaging studies to
confirm the mino salivary gland
origin.

21. Preoperative preparation:
1. Computed tomography scan whin
contrast medium or magnetic resonance
imaging scan with gadolinium
enhancement.
2. Fine-needle aspiration through the
transoral route confirms the presence of
a benign tumour.
3. The patient should be aware in the
intraoral operation may be extended to
included a cervical –parotid approach
and possible mandibulectomy.

22. Tips and pearls:
1. Wide exposure before identifying
the facial nerve.
2. Meticulous dissection on the nerve
at all times.
3. Minimal use of a nerve stimulator.

23. Excision of all of the parotid gland while
sparing the seventh cranial nerve
Indications:
1- Large benign or malignant neoplasma.
2- Deep-lobe neoplasma .
3- Chronic or chronic recurrent sialadenitis.
4- Some cases of metastatic

24. Pitfalls and complications:
1. Attempting to identify the facial
nerve without wide exposure and
excellent visualisation.
2. Attempting to identify the facial
nerve with poor hemostasis.
3. Inadvertent incision into the tumour
while dissecting out the facial nerve.

25. Total excision of all of the parotid gland
and facial nerve repair of the verve by
grafting.
Indications:
1- Malignant neoplasma involving the facial
nerve.
2- Rarely , the multiply recurrent
pleomorphic adenoma after all els has
failed.

26. Special considerations:
1. Extensive involvement of the facial
nerve, because spread may go
proximally into the temporal bone.

27. Special instruments, positions and
anaesthesia:
1. Headlight .
2. Hypotensive anaesthesia.
3. Operating microscope.
4. Orbital or cummings retractors.
5. Microinstruments for nerve repair.
6. Prep and drape expected nerve donor
site.

28. Pitfalls and complications:
1. Tumour may have extended
medially along the nerve into the
temporal bone.
2. Level two lymph nodes should be
examined.

29. Tips and pearls:
1. Wide exposure before
identification of the main trunk of
the facial nerve.
2. Careful tagging of the distal
branches of the facial nerve as they
are identified.