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

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

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.

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

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.

Sublingual Salivary Gland

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.

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.

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 .

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.

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.

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

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 .

sialogram

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)

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.

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.

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.

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

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 )

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

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.

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

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.

- 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).

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.

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.

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.

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

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.)

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.

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.

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

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

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

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

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)