1. Salivary Glands Dr. ZAID MUWAFAQ AL-HAMID
MRCS England(UK), FJMC Jordan, HSM SURGERY Jordan, MBChB Mosul
Specialist General & Laparoscopic Surgeon

2. Anatomy of salivary glands
Two submandibular glands
Two parotid glands
Two sublingual glands
Approximately 450 minor salivary glands

3. Common disorders of minor salivary glands
1- Extravasation Cysts
Common
trauma to the overlying mucosa.
affect lower lip  producing painless swelling and usually translucent .
resolve spontaneously
most require formal surgical excision +overlying mucosa +underlying minor salivary gland.
Recurrence is rare.

4. Tumours of minor salivary glands
90 % malignant.
anywhere in the upper aerodigestive tract
common sites : upper lip, palate and retromolar regions.
Less common sites nasal and pharyngeal cavities.
Benign minor salivary gland tumors present as painless, firm, slow-growing swellings. Overlying ulceration is extremely rare.
Treatment: excision of the tumor +overlying mucosa+ primary closure

5. Malignant minor salivary gland tumours
rare.
Firm
discoloration overlying mucosa (pink to blue or black) .
late necrotic with ulceration.
Treatmentwide excision +/- partial or total maxillectomy + reconstruction.

6. Sublingual Salivary Gland

7. Common disorders of the sublingual glands
1- Cysts(ranula)
mucous extravasation cyst that arises from a sublingual
gland.
- translucent swelling ‘frog’s belly’ .
resolve spontaneously.
many require formal surgical excision of the cyst and the affected sublingual gland.

9. 2- Plunging ranula rare mucous retention cyst
arise from sublingual and submandibular s g.
Mucus collects within the cyst, which perforates through the mylohyoid muscle diaphragm to enter the neck.
dumb-bell-shaped swelling
Soft
fluctuant
Painless
in the submandibular or submental region of the neck .
Diagnosis : ultrasound or magnetic resonance imaging (MRI).
Treatment:
- Excision transcervical ( removing the cyst+ submandibular+ sublingual glands).
- Smaller plunging ranulas transoral sublingual gland excision+/- marsupialisation.

10. Tumors of sublingual - extremely rare 85 per malignant. hard or firm
painless swelling
in the floor of the mouth.
Treatment
wide excision + overlying mucosa+ neck dissection. +reconstruction .

11. THE SUBMANDIBULAR GLANDS
Ectopic/aberrant salivary gland tissue
Stafne bone cyst
- most common ectopic salivary tissue .
Asymptomatic
clearly demarcated radiolucency of the angle of the mandible.
below the inferior dental neurovascular bundle.
No treatment is required.

12. Inflammatory disorders of the submandibular gland(sialadenitis)
acute, chronic or acute on chronic.
Common causes are:
Acute submandibular sialadenitis:
1- Bacterial sialadenitis
more common than viral sialadenitis
- secondary to obstruction.
- antibiotics, if chronically inflamed  formal excision.
2- Viral. The paramyxovirus (mumps)
Usually parotitis.
occasionally submandibular glands
painful tender swollen glands.
Other viral infections rare.
Chronic submandibular sialadenitis.

13. Obstruction and trauma to submandibular gland
Stone formation (sialothiasis): most common cause of obstruction within the submandibular gland is within the gland and duct system. 80%of all salivary stones occur in the submandibular glands because highly viscous secretions . 80% submandibular stones are radio-opaque

14. Clinical symptoms
acute painful swelling in the region of the submandibular gland
precipitated by eating
completely obstruct(less common) opening of the submandibular ductswelling develop rapidly 1–2 hours after the meal resolves spontaneously
partial obstruction(more common) (hilum of the gland or within duct in the floor of the mouth)
- infrequent symptoms
- minimal discomfort and swelling
- not confined to mealtimes.
- examination  enlarged firm submandibular gland, tender on bimanual examination.
Pus from the sublingual papilla .

15. sialogram

16. Management stone within the submandibular duct in the floor of the mouth anterior to the point at which the duct crosses the lingual nerve (second molar region) incising over the duct+stone delivered+ leave the wall of the duct stone is proximal to the lingual nervesubmandibular gland excision a removal of the stone + ligation of the submandibular duct endoscopic retrieval of stone, lithotripsy(sialadenoscope)

17. Submandibular gland excision
Indication: sialadenitis Salivary tumours. Complications: • haematoma • wound infection • marginal mandibular nerve injury • lingual nerve injury • hypoglossal nerve injury • transection of the nerve to the mylohyoid muscle producing submental skin anaesthesia.

18. Tumours of the submandibular gland
- uncommon
- (benign and malignant)present as a slow-growing, painless swelling within the submandibular triangle.
50 % of submandibular gland tumours are benign.
pain is not a reliable indication of malignancy as benign tumours often present with pain in the affected gland, presumably due to capsular distension or outflow obstruction.

19. Clinical features of malignant salivary tumours
• facial nerve weakness • rapid enlargement of the swelling • induration and/or ulceration of the overlying skin • cervical node enlargement.

20. Investigation
1-Computed tomography (CT) and MRI scanning the extension, circumscribed (benign, or diffuse, invasive and probably malignant). 2- Biopsy Open surgical biopsy is contraindicated as this may seed the tumour into surrounding tissues, making it impossible to eradicate microscopic deposits of tumour cells. Fine-needle aspiration biopsy no risk of seeding viable

21. Management of submandibular gland tumours
surgical excision with a cuff of normal tissue is the goal.
- Small tumor+ localised ( entirely within the submandibular gland parenchyma)
 intracapsular submandibular gland excision is
- Benign tumors (large and beyond the submandibular gland) suprahyoid neck dissection
(preserving the marginal mandibular branch of the facial nerve, lingual nerve and hypoglossal nerves).
- Overt malignancymodified neck dissection /radical neck dissection .
(may sacrifice of the lingual and hypoglossal nerves )

23. THE PAROTID GLAND Developmental disorders Rare
agenesis, duct atresia and congenital fistula

24. Inflammatory disorders
Viral infections
Mumps (most common)
acute painful parotid swelling
Mostly affects children.
spread by airborne droplets .
1–2 days fever, nausea and headache
 pain and swelling in parotid glands.
pain very severe and exacerbated by eating and drinking.
Symptoms resolve within 5–10 days.
Treatment : regular paracetamol + adequate oral fluid intake.
Complications
orchitis, oophoritis, pancreatitis, sensorineural deafness and meningoencephalitis are rare.
Other viral agents that produce parotitis include Coxsackie A and B, parainfluenza 1 and 3, Echo and lymphocytic choriomeningitis.

25. Bacterial infections Acute ascending bacterial sialadenitis
dehydrated elderly patients following major surgery
 Reduced salivary flow ascending infection.
Staphylococcus aureus /Streptococcus viridans
Can occur with no obvious precipitating factors.
presentation tender, painful parotid swelling that arises over several hours .
generalised malaise, pyrexia and occasional cervical lymphadenopathy.
The pain is exacerbated by eating or drinking.
The parotid swelling may be diffuse/localises (lower pole of the gland)
Pus may exuding from the parotid gland papilla

26. Treatment: - intravenous antibiotics
Treatment: - intravenous antibiotics. abscess  drainage (large bore needle aspiration / drainage under general anaesthesia Chronic bacterial sialadenitis is rare in the parotid gland.

27. - Recurrent parotitis of childhood - Obstructive parotitis
Papillary obstruction
less common than obstructive submandibular sialadenitis
caused by trauma to the parotid papilla
overextended upper denture flange or a fractured upper molar tooth.
inflammation and oedema obstructs salivary flow(mealtimes)
rapid onset pain and swelling at mealtimes.
untreated progressive scarring and fibrosis in and around the parotid duct papilla will produce a permanent stenosis.
Treatment: papillotomy(under either local or general anaesthesia).

28. Stone formation(Sialolithiasis) - less common in the parotid gland (20 %) (submandibular gland (80 %). - Parotid duct stones  radiolucent. - Stone either proximal in the collecting duct or distal near the papilla. - Diagnosis: Parotid gland sialography. - Treatment: stone located in the collecting duct or within the gland  endoscopic retrieval, lithotripsy or rarely parotidectomy.

29. Tumours of the parotid gland
- The parotid gland is the most common site for salivary tumors.
Most tumors arise in the superficial lobe
80–90 % of tumours of the parotid gland are benign
the most common is pleomorphic
Slow growing, painless swellings below the ear, in front of the ear or in the upper aspect of the neck.
- Less commonly, tumors in accessory lobe persistent swellings in the cheek.
- Rarely, tumours in deep lobe as parapharyngeal massesdifficulty in swallowing and snoring.

30. Malignant salivary gland tumours are divided into two
distinct subgroups:
1- Low-grade malignant tumours, e.g. acinic cell carcinoma,
are indistinguishable on clinical examination from benign
neoplasms.
2- High-grade malignant tumours :
Rapidly growing
painless swellings
discrete mass with infiltration into the overlying skin
or diffuse + hard swelling + no discrete mass(advanced disease)
- Cervical lymph node metastases.

31. Investigations CT and MRI scanning Fine-needle aspiration biopsy
(open surgical biopsy is contraindicated )
(no enucleation even if a benign lesion is suspected)

32. Treatment of parotid tumor
Superficial parotidectomy for Superficial lobe tumor The aim of superficial parotidectomy is to remove the tumor with a cuff of normal surrounding tissue. Low-grade malignant tumours superficial parotidectomy. Radical parotidectomy Indicated in high-grade malignant tumour(squamous cell carcinoma) Radical parotidectomy = removal of all parotid gland tissue +sectioning of the facial nerve+ ipsilateral masseter muscle +/- neck dissection(if positive LN mets.)

34. Complications of parotid gland surgery
• haematoma formation; • infection • temporary facial nerve weakness • transection of the facial nerve and permanent facial weakness • sialocoele • facial numbness • permanent numbness of the ear lobe associated with great auricular nerve transection; • Frey’s syndrome.

35. Frey’s syndrome Frey’s syndrome (gustatory sweating)
- damage to the autonomic innervation of the salivary gland with inappropriate regeneration of parasympathetic nerve fibres that stimulate the sweat glands of the overlying skin.
sweating and erythema over the region of surgical excision of the parotid gland as a consequence of autonomic stimulation of salivation by the smell or taste of food.
Dgxstarch iodine test.
Rx antiperspirants( aluminium chloride)
denervation by tympanic neurectomy;
botulinum toxin injection into the affected skin.

37. Pleomorphic adenoma Benign Tumor The most common salivary T.
- On gross inspection : tumors is smooth and lobular and demonstrates a well defined capsule
On microscopic examination : both epithelial and mesenchymal elements are present
MOST COMMON NEOPLASM IN THE PAROTID GLAND ACCOUNTS FOR 65% OF ALL OF THE PAROTID TUMORS.
The most common salivary T.
In middle aged & more in woman than in men,
Slowly growing

39. Treatment :
Superficial parotidectomy
WIDE RESECTION OF THE TUMOR
AVOID SHELLING OUT THE LESION
RECURRENCE: PRIMARY DUE TO INADEQUATE RESECTION
LESIONS ARE MORE AGGRESSIVE WHEN THEY RECUR

40. WARTHIN’S TUMOR (ADENOLYMPHOMA)
SECOND MOST COMMON PAROTID TUMOR
MALE : FEMALE 5 : 1
BILATERAL 10%
May (MULTICENTRICITY).
TREATMENT: superficial parotidectomy
90%CURED WITH RESECTION
10%RECUR DUE TO MULTICENTRICITY OR INADEQUATE RESECTION

41. Malignant neoplasm Mucoepidermoid carcinoma Adenoid cystic carcinoma
Acinic cell carcinoma
adeno carcinoma
Carcinoma Ex. Pleomorphic adenoma or malignant mixed tumor
Squamous cell carcinoma
Undifferentiated carcinoma
miscellaneous

42. Other diseases of salivary glands
A-Granulomatous sialadenitis:
Mycobacterial infection
Sarcoidosis
B-Tumour-like lesions
Sialadenosis
C-Degenerative conditions
- Sjögren’s syndrome
autoimmune condition causing progressive
destruction of salivary and lacrimal glands.
- Benign lymphoepithelial lesion
Xerostomia(decrease salivary flow)
Sialorrhoea(increase salivary flow)