Detailed discussion on surgical anatomy of salivary glands with special focus on major glands. Relationship of facial nerve and its branhes to parotid gland is also discussed. Complications are also discussed. Surgical approaches are also discussed.

1. ANATOMY
OF
SALIVARY
GLANDS
AND ITS
APPLIED
ASPECTS
P R ES E N T E D BY -
D R . D I BYA FA LG O O N
S A R K A R

2. INTRODUCTION
• The salivary glands are exocrine glands, glands with
ducts, that produce saliva and pour their secretion in the
oral cavity
• The major function of the salivary glands is to secrete
saliva, which plays a significant role in lubrication,
digestion, immunity, and the overall maintenanceof
homeostasis within the human body .
Major (Paired)
• Parotid
• Submandibular
• Sublingual
Minor - Those in
the Tongue,
Palatine Tonsil,
Palate,Lips and
Cheeks

3. PAROTID GLAND
• Largest major salivary
gland (15-30g weight)
• Pyramidal shaped
irregular lobulated
mass lying mainly
below the external
acoustic meatus
between mandible and
sternomastoid.
• They are compound
tubuloalveolar glands
with acini lined by
seromucous cells

4. PAROTID CAPSULE
• Derived from investing layer of deep
cervical fascia which splits into
superficial and deep layers to enclose
the parotid gland.
• Superficial lamina-Extends
superiorly from the masseter to
zygomatic arch. Thick and closely
adherent-sends fibrous septa into
the gland.
• Deep lamina-thin- attached to
styloid process, mandible and
tympanic plate. Extends upto the
stylomandibular ligament.

5. • Stylomandibular ligament- Separates the superficial and deep
lobes of the parotid gland and also the submandibular gland from
the parotid. The stylomandibular ligamentis an important
surgical landmark when considering the resection of deep
lobe tumors . In fact,stylomandibular tenotomy can be a
crucial maneuver in providing exposure for en bloc
resections of deep-lobe parotid or other parapharyngeal
space tumors .
( Holsinger & Bui - Springer Publication)

6. ANATOMY OF PAROTID GLANDS

7. ANATOMY OF PAROTID GLAND
• Resembles an inverted 3 sided pyramid
• Four surfaces 1. Superior(Base of the Pyramid) 2.Superficial
3. Anteromedial 4. Posteromedial
• Superior Surface is Concave :
Related to 1. Cartilaginous part of ext acoustic meatus 2. Post. Aspect of
temperomandibular joint 3. Auriculotemporal Nerve 4. Superficial temporal vessels
• Apex : Overlaps posterior belly of digastric and adjoining part of carotid triangle
• Superficial Surface : Covered by 1. Skin 2. Superficial fascia containing facial branches of great
auricular Nerve 3. Superficial parotid lymph nodes and post fibers of platysma
• Anteromedial Surface : Grooved by posterior border of ramus of mandible
Related to • Masseter • Lateral Surface of temperomandibular joint • Medial pterygoid
muscles • Emerging branches of Facial N
• Posteromedial Surface:
Related • to mastoid process with sternomastoid and posterior belly of digastric.
•Styloid process with structures attached to it.
• External Carotid A. which enters the gland through the surface
• Internal Carotid A. which lies deep

8. BORDERS OF PAROTID GLAND

9. ACCESSORY PAROTID GLAND
• Accessory parotid gland mayalso
be present lying anteriorly
over the masseter muscle
between the parotid duct
and zygoma .Its ducts empty
directly into the parotid duct
through one tributary .
• Accessory glandular tissue
is histologicallydistinct from
parotid tissue in thatit
maycontain mucinous acinar
cellsin addition to the serous
acinar cells

10. STRUCTURES WITHIN PAROTID GLAND
• Facial Nerve
• Retromandibular vein
• External carotid artery

11. FACIAL NERVE
• FACIAL NERVE Is intimately
aasociated with the parotid gland,
and understanding its anatomy is
important for parotid surgeries.
• It divides the parotid into
superficial and deep lobes
• Exits from the stylomastoid
foramen and gives the posterior
auricular and to posterior belly of
digastric, before entering into the
parotid
• Within the parotid gland facial
nerve forms the pes anserinus
pattern of branching

12. • Davis et al described six different facial nerve branching patterns with no
predominant pattern.
• The major variations are in the origin of the buccal branch and the degree of
cross innervations between adjacent terminal branches

13. VEINS PASSING THROUGH PAROTID GLAND

14. ARTERIES PASSING THROUGH PAROTID GLAND

15. PAROTID DUCT
Ductus parotideus; Stensen’s duct
• 5 cm in length
• Appears in the anterior border of the gland
• Runs anteriorly and downwards on the masseter b/w the upper and lower
buccal branches of facial N.
•At the anterior border of masseter it pierces
• Buccal pad of fat • Buccopharyngeal fascia • Buccinator Muscle
•It opens into the vestibule of mouth opposite to the 2nd upper molar

17. NERVE SUPPLY OF PAROTID GLAND

18. INCISIONS USED IN PAROTID SURGERY

19. OPERATIVE TECHNIQUES FOR PAROTIDECTOMY
• A modified Blair incision is given in the natural crease just anterior
to the helix and extends underneath the earlobe and superiorly
over mastoid process
• Then the incision curves inferiorly along anterior border of SCM
• Incision continues below angle of mandible at distance safe from
marginal mandibular nerve
• Dissection is carried to the depth of parotid fascia and the
platysma
• Tail of parotid is separated from the SCM
• Greater auricular nerve is to be preserved to maintain sensation
to earlobe ( Lore et al 2004)

20. SURGICAL LANDMARKS FOR
IDENTIFICATION OF FACIAL NERVE
• Tragal pointer - The main trunk of the facial
nerve is located 1 cm anteroinferior and 1
cm deep to the tip of the tragal cartilage.
• Digastric ridge- The main trunk is just
superior to the attachment of the posterior
belly of the digastric muscle to the digastric
groove. This landmark also marks the
approximate depth of the facial nerve.
• Stylomastoid foramen - The base of the
styloid process is 5 to 8 mm deep to the
tympanomastoid suture line. The facial
nerve can be identified as it exits the
stylomastoid foramen and passes over the
posterolateral aspect of the styloid process.
• Tympanomastoid suture line - The nerve
lies 6 to 8 mm deep to the inferior end of
the tympanomastoid suture line.
• Mastoid - For revision cases, extensive
tumors or, as a last resort, a mastoidectomy
can be performed to locate the vertical
segment of the facial nerve, which can then
be followed as it exits the mastoid.

21. Identifying facial nerve intra operatively

22. APPLIED ASPECTS
• Parotid swellings are very painful due to
the unyeilding nature of the parotid fascia.
• Parotid abscess is best drained by
horizontal incision according to Hiltons
method of incision and drainage.
Vertical incision on skin but transverse
incision on the parotid fascia to safeguard
facial nerve and branches
• Gustatory sweating, also known as Frey’s
syndrome, presents as redness and
perspiration over the cheek and parotid
region in anticipation of eating. This
complication may develop several years
after parotidectomy and occurs when
severed parasympathetic nerves to the
parotid gland regenerate in an aberrant
fashion and innervate sweat glands in the
dermis.

23. SUBMANDIBULAR
GLAND

24. ANATOMY OF SUBMANDIBULAR GLAND
• The submandibular gland (“the
submaxillary gland”) is the second
largest major salivary gland and
weighs 7–16g.
• The gland is located in the
submandibular triangle.
• Large superficial and small deeper part
continous with each other around the
posterior border of mylohyoid.
• During neckdissection or subman-
dibular gland excision, this
mylohyoid muscle must be
gently retracted anteriorlyto expose
the lingual nerve and
submandibular ganglion .

25. FASCIA ENCLOSING THE SUBMANDIBULAR GLAND
• The middle layer of the deep
cervical fascia encloses the
submandibular gland .
• This fascia is clinically relevant
because the marginal mandibular
branch of the facial nerve is
superficial to it, and care must
be taken to preserve the nerve
during surgery in the submandibular
region . Thus, division of the
submandibular gland fascia,
when oncologically appropriate, is
a reliable method of preserving
and protecting the marginal
mandibular branch of the facial
nerve during neckdissection
and/or submandibular gland
resection .

26. RELATIONS OF SUBMANDIBULAR GLAND
• Inferiorly- covered by • Skin • Superficial fascia containing platysma and
cervical branches of facial N • Deep Fascia • Facial Vein • Submandibular Nodes
• Lateral surface • Related to submandibular fossa on the mandible • Mandibular
attachment of Medial pterygoid • Facial Artery
• Medial surface
• Anterior part- is related to mylohyoid muscle, nerve and vessels
• Middle part - Hyoglossus, styloglossus, lingual nerve, submandibular ganglion,
hypoglossal nerve and deep lingual vein.
• Posterior Part - Styloglossus, stylohyoid ligament,9th nerve and wall of pharynx
• Deep part • Small in size
•Lies deep to mylohyoid and superficial to hyoglossus and styloglossus
• Posteriorly continuous with superficial part around the posterior
border mylohyoid

27. SUBMANDIBULAR DUCT
• Wharton’s duct (5 cm long)
• Emerges at the anterior
end of deep part of the
gland
• Runs forwards on
hyoglossus b/w lingual and
hypoglossal N
• At the ant. Border of
hyoglossus it is crossed by
lingual nerve • Opens in
the floor of mouth at the
side of frenulum of tongue

28. BLOOD SUPPLY AND LYMPHATIC DRAINAGE OF
SUBMANDIBULAR GLANDS
• Arteries - Branches of facial and lingual arteries
• Veins - Drains to the corresponding veins
• Lymphatics - Deep Cervical Nodes via
submandibular nodes

30. APPLIED ASPECTS
• The formation of calculus is more common in the submandibular gland than in
the parotid.
• For excision of the submandibular salivary gland( for calculus or tumour), a skin
crease incision is as a rule, given more than 1inch( 2.5cm) below the angle of the
jaw .
• A stone in the submandibular duct(wharton’s duct) can be palpated bimanually
in the floor of the mouth and can even be seen if sufficiently large.

31. EXTRAORAL INCISIONS USED IN
SUBMANDIBULAR GLAND RESECTION
• Placed 2-4 cm below the
mandible, parallel to it
• Preserve :
• Marginal mandibular nerve
• Lingual nerve
• Hypoglossal nerve

33. KEY POINTS DURING SUBMANDIBULAR GLAND
EXCISION
• A safe way to preserve the marginal nerve is to ligate the facial vein and
incise the submandibular gland fascia at the inferior border of the gland.
These tissues can then be lifted from the gland along with the marginal nerve.
• The hypoglossal nerve should be identified adjacent to the intermediate
tendon of the digastric muscle.
• The facial artery is encountered on the posterior aspect of the gland as it
passes deep to the posterior belly of the digastric and enters the
submandibular gland. The facial artery is then ligated, taking care to preserve
the hypoglossal nerve.
• The lingual nerve and efferent fibers of the chorda tympani can be identified
deep to the mylohyoid muscle along with the submandibular ganglion. Just
medial to the lingual nerve is Wharton’s duct.
• Wharton’s duct should be ligated to prevent retrograde spread of infection
from mouth. (Hsu et al 2009)

34. INTRAORAL APPROACH TO
SUBMANDIBULAR GLANDS
• This procedure is anatomically safe and can be performed with minimal
morbidity
• Infiltration with Xylocaine plus epinephrine with an adequate waiting period for
hemostasis; The intraoral approach (IOA) consisted of an incision on the floor of
mouth from the caruncle of Wharton's duct to the retromolar trigone
• careful identification of the submandibular duct/lingual nerve relationship;
• Anterior retraction of the mylohyoid muscle to expose the superficial lobe;
• superiorly directed, extraoral, manipulation of the submandibular gland;
• close and blunt dissection to the gland laterally to avoid injury to the facial
artery and vein.
(PMID: 10839409 [PubMed - indexed for MEDLINE] Division of Plastic and
Reconstructive Surgery at the University of California, Los Angeles 90095-1665,
USA.)

35. COMPLICATIONS
• Transient weakness can also occur from
stretch injury to the marginal nerve during
surgery
• Haematoma - The management of
postoperative hematoma is wound
exploration, clot evacuation, and
hemostasis with bipolar cautery to avoid
thermal injury to the marginal mandibular
nerve.

36. SUBLINGUAL GLAND

37. ANATOMY OF SUBLINGUAL GLAND
• Smallest of the three glands
• Weighs nearly 3-4 gm
• Lies beneath the oral mucosa
in contact with the sublingual
fossa on lingual aspect of
mandible
Duct (Ducts of Rivinus )
• 8-20 ducts
• Most of them open directly
into the floor of mouth • Few
join the submandibular duct

38. RELATIONS OF SUBLINGUAL GLAND
•Above - Mucosa of oral
floor, raised as sublingual fold
•Below - Mylohyoid Infront ,
Anterior end of its fellow
•Behind -Deep part of
Submandibular gland
•Lateral -Mandible above the
anterior part of mylohyoid
line
•Medial -Genioglossus and
separated from it by lingual
nerve and submandibular
duct

39. •Blood supply
• Arterial from sublingual and submental arteries
• Venous drainage corresponds to the arteries
•Nerve Supply
Similar to that of submandibular glands(via lingual nerve ,
chorda tympani and sympathetic fibers)

40. SURGICAL APPROACH TO SUBLINGUAL GLAND
- linear incision is made
parellel and lateral to
submandibular duct
- incision shouldn’t extend
more posteriorly to 1st
molar tooth to avoid
damage to lingual nerve
- the submandibular duct is
carefully identified and
retracted medially
- stay sutures-passing
through margins of mucosa
to aid in retention

41. • Using blunt dissection(scissors)
lingual nerve is identified -the
sublingual gland lying adjacent to
inner cortex of mandible is
mobilized and its multiple ducts
are divided carefully to avoid
damage to it.
• The anterolateral part of
sublingual gland may be attached
to periosteum of mandible by
fibrous tissue which must be
divided carefully. followed by
removal of gland as and when
necessary

42. APPLIED ASPECTS
• The structures at risk during dissection of the
gland are the submandibular duct and the
lingual nerve.
• The duct lies superficially in the floor of the
mouth medial to the sublingual fold, and is
crossed inferiorly by the nerve which then enters
the tongue
• The sublingual artery and vein also lie on the
medial aspect of the gland close to the
submandibular duct and lingual nerve.

43. CONCLUSION
• Surgical techniques for salivary gland surgery will
continue to evolve as technologies develop.
• A thorough understanding of the disease
processes and anatomy will remain of paramount
importance in the successful surgical management
of salivary gland diseases.