GOOD MORNING

SURGICAL ANATOMY OF MAJOR SALIVARY GLANDS

(DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY)

PRESENTED BY: GUIDED BY:

Dr. Samarth Johari Dr. D S Gupta
P.G 1st Year (Professor)
04-12-2018
(Tuesday)
 CONTENTS
 Introduction

 Development of Salivary Glands

 Parotid Gland

 Submandibular Gland

 Sublingual Gland

 Evaluation of Salivary Glands

 Conclusion

 References
 INTRODUCTION
 Exocrine Glands that open or secrete into oral cavity

 Major function secretes saliva

 Saliva fluid which has partly chemical & partly physical functions

its enzymes initiates 1st phase of

digestion & has antibacterial
action related to dental caries

moistens & lubricates food

 Anatomically, divided into 2 groups :
i. Major salivary glands
• Larger in size
• Situated farther from inner lining of oral cavity & open with strong, wide
ducts
• Includes paired –
a) Parotid
b) Submandibular
c) sublingual glands

ii. Minor salivary glands

• Smaller in size
• Situated in the mucous layer & open with numerous narrow ducts on
mucous membrane
• Divided according to their site -
a) Palatine b) Lingual c) Incisive
d) Labial e) Buccal
 According to their secretion, divided as –
i. Serous (albuminous) :
• Consists of serous acini
•
is responsible for digestion of starches
ᵅ
Responsible for serous secretion that contains ptyalin ( -amylase) which

ii. Mucous :
• Consists of mucous acini
• Responsible for mucous secretion that contains mucin for lubrication &
surface protecting purposes

iii. Mixed :
• Consists of both serous & mucous acini
 DEVELOPMENT OF
SALIVARY GLANDS
 Originate from oral epithelial buds
invading underlying
ectomesenchyme

 Origin of epithelial buds –

i. Ectodermal in parotid &
minor salivary glands
ii. Endodermal in
submandibular & sublingual
glands

 Connective tissue stroma & blood

vessels originate from
mesenchyme
 Major salivary glands develop in 6 main
stages :
i. Bud formation via introduction of oral
epithelium by underlying mesenchyme

ii. Formation & growth of epithelial cord

iii. Initiation of branching in terminal

parts of epithelial cord & continuation
of glandular differentiation

iv. Dichromatous branching of epithelial

cord & lobule formation

v. Canalization of presumptive ducts

vi. Cytodifferentiation
 PAROTID GLAND
 Largest & weighs on an average – 15-30gm

 Bulk of gland situated in retromandibular

fossa

 Lies in shallow triangular shaped trench

formed by :
i. Posteriorly - Sternocleidomastoid muscle
ii. Anteriorly – ramus of mandible
iii. Superiorly (base of trench) – external
acoustic meatus (situated in groove of
gland) & posterior aspect of zygomatic
arch
 Extends anteriorly over masseter & inferiorly over posterior belly of digastric
muscle
 In most persons, gland is divided into 2 lobes :
i. Superficial lobe – comprises of bulk of gland
ii. Deep lobe

 2 lobes are connected by narrow isthmus

mostly found in bifurcation of facial nerve into upper temporal & lower cervical
division

 Branches of facial nerve lies b/w these lobes for a short distance

 An accessory parotid gland (socia parotidis) may also be present lying

anteriorly over masseter muscle b/w parotid duct & zygoma

Is different from parotid tissue as it may contain both mucinar & serous acini & its
ducts empty directly into parotid duct through 1 tributary
 Fascia/Capsule of parotid gland :
• Capsule continuation of deep
cervical fascia & splits into superficial
& deep layers to enclose parotid
gland

Extends to stylomandibular ligament

which seperates superficial
& deep lobes of parotid gland

Is thick & extends superiorly from

masseter & sternocleidomastoid to
zygomatic arch

• Is dense & inelastic because it covers

masseter deeply (parotid masseteric  Parotid swellings are very
fascia) painful
 Stensen’s Duct :
• Aka ductus parotideus

• Secretes serous saliva

into vestibule

• From anterior border of

gland runs parallel to
zygoma (approx. 1cm
below it) in anterior
direction across
masseter muscle Parotid Duct Injury

Then turns sharply to  may be damaged in injuries to the face

pierce buccinators muscle
to enter oral cavity opposite  may be inadvertently cut during surgical
to maxillary 2nd molar operations on the face
 Neural Anatomy :
• Facial nerve exits skull from
stylomastoid foramen & its main trunk,
in parotid gland (at pes anserinus :
goose foot), divides into upper
temporofacial & lower cervicofacial
divisions approx. 1.3 cm from
stylomastoid foramen

• Upper temporofacial division –

forms of temporal, zygomatic & buccal
branches

• Lower cervicofacial division – forms

marginal mandibular & cervical
branches
 Facial nerve courses through the gland without supplying any structure in it
 Nerve Supply :
• Parasympathetic –
secretomotor through
auriculotemporal nerve

• Sympathetic –
vasomotor through
external carotid plexus
from superior cervical
ganglion. Also supplies
sweat glands, cutaneous
blood supply

• Sensory – through
auriculotemporal nerve
 Parotid fascia is innervated by sensory fibers of great auricular nerve (C2,
C3)
 Frey’s Syndrome

 Aka “gustatory sweating”

 Seen after parotidectomy

 Acetylcholine acts as
neurotransmitter for both
postganglionic sympathetic &
parasympathetic fibers & there may
be re-innervation of sweat glands by Minimizing Risk Of Frey’s
regeneration of parasympathetic Syndrome
fibers from residual parotid gland  Complete & meticulous
superficial paroidectomy
Patients develop sweating & flushing of  Developing skin flaps of
skin overlying parotid region while appropriate thickness over
chewing exposed apocrine glands of skin
 Arterial Supply :
• From branches of external carotid
artery (superficial temporal artery,
maxillary artery & transverse facial
artery)

 Venous Drainage :
• Maxillary vein + superficial temporal vein

Retromandibular vein

Anterior branch Posterior branch

Unites with Unites with
posterior facial posterior
vein to form auricular vein to
common facial drain into external
vein jugular vein
 Lymphatic Drainage :
• Only salivary gland with 2 nodal layers, both of which drain into superficial &
deep cervical lymph systems

• 90% nodes are in superficial layer b/w gland & its capsule

i. Superficial Nodes – drain parotid gland, external auditory canal, pinna,

scalp, eyelids & lacrimal glands

ii. Deep Nodes – drain gland, external auditory canal, middle ear,
nasopharynx & soft palate
 Parotid Infection

 Parotid abscess may be caused by

spread of infection from oral cavity
 Parotid lymph node draining an
infected area may also cause parotid
infection
 Parotitis/Mumps is an infection of
parotid gland caused by
paromyxovirus & causes severe pain
Drainage of Parotid Abscess

 Done on the basis of Hilton’s method of

incision & drainage
 Vertical incision in front of ear & then a
transverse incision to protect the branches of
facial nerve.
 Parapharyngeal Space :
• Tumors of deep parotid lobe extend
medially into PPS
• Just posterior to infratemporal fossa like
inverted pyramid in shape
• Boundaries :
i. Apex – greater cornu of hyoid bone
ii. Base – petrous bone of skull base
iii. Medial – lateral pharyngeal wall
(includes superior constrictor,
buccopharyngeal fascia, tensor veli
palatine)
iv. Lateral – ramus, medial pterygoid
v. Anterior – pterygoid fascia,
pterygomandibular raphae
vi. Posterior – carotid sheath,
prevertebral fascia
 Surgical Approach to Parotid Gland :

• Cervicomastoidfacial Incision –
 Given by Blair in 1912 &
modified by Bailey in 1941

 Modification is aka “lazy ‘s’

incision”

 Incision is given in relaxed

preauricular skin crease, curves
around lobule toward mastoid
tip & then anteriorly along
natural skin crease, curving
approx. 2 finger breadths below
angle of mandible
 SUBMANDIBULAR GLAND
 Earlier was called “submaxillary gland”

 2nd largest major salivary gland & weighs 7-

16gm

 Located in submandibular triangle –

• Superior boundary formed by inferior
border of mandible
• Inferior boundaries formed by anterior
belly & posterior belly of digastric

 Other structures that lie in this triangle are

submandibular lymph nodes, facial artery &
vein, mylohyoid muscle & lingual, hypoglossal
& mylohyoid nerves
 Most part of submandibular
salivary gland lies posterolateral
to mylohyoid muscle

During neck dissection or

submandibular gland excision,
mylohyoid muscle must be gently
retracted to expose lingual nerve
& submandibular ganglion
 Fascia/Capsule of submandibular gland :
• Enclosed by middle layer of deep
cervical fascia

• Superficial layer is attached to base of

mandible

• Deep layer is attached to mylohyoid line

of mandible
 Marginal mandibular branch of facial nerve is superficial to this fascia,
therefore, care has to be taken while performing surgeries in
submandibular region

 Division of submandibular gland fascia (when oncologically appropriate)

is a reliable method of preserving & protecting marginal mandibular
branch of facial nerve during neck dissection & submandibular gland
resection
 Wharton’s Duct :
• Has both serous & mucous cells which
empty into submandibular duct via
ductules

• Exits anteriorly from sublingual aspect

of gland (deep to lingual nerve & medial
to sublingual gland)

• Forms Wharton’s duct (approx. 4-5 cm

long) b/w hyoglossus & mylohyoid on
genioglossus

• Empties lateral to lingual frenulum

through papilla in floor of mouth behind
lower incisor teeth
 Nerve Supply :
• Parasympathetic –
secretomotor from
superior salivatory
nucleus in pons passes
through nervus
intermedius & further
joins facial nerve

• Sympathetic –
vasomotor through
superior cervical ganglion
via lingual artery &
causes mucoid secretion

• Sensory – through
auriculotemporal nerve
 Arterial Supply :
• Main blood supply is by facial artery
& its branch submental artery

• Runs medial to posterior belly of

digastric

• Artery exits at superior border of

the gland & at the inferior border of
mandible (at facial notch)

• then runs adjacent to inferior

branches of facial nerve
 During submandibular gland resection, facial artery must be sacrificed
twice –
1st at inferior border of mandible
2nd just superior to posterior belly of digastric
 Venous Drainage :
• Mainly drained by anterior facial
vein

Anastomoses with infraorbital &

superior ophthalmic veins
• Over the middle aspect of the
gland, union of anterior facial vein
& posterior facial vein forms
common facial vein

exits submandibular triangle to join

internal jugular vein
 Since, anterior facial vein lies just deep to marginal mandibular division of
facial nerve, its ligation & superior retraction can help preserve marginal
mandibular nerve
 Lymphatic Drainage :
• Prevascular & postvascular lymph
nodes drain submandibular gland

• Not embedded in tissue but present

b/w gland & its fascia

• Lie in close approximation to facial

artery & vein at superior aspect of
gland

• Frequently associated with oral

cancers (specially in buccal mucosa
& floor of mouth)
 While ligating facial artery & its associated structures care must be taken
not only to resect all associated lymphoadipose tissue, but also to preserve
marginal mandibular nerve which runs close to it
 Sialolithiasis is more common in
submandibular salivary glands because :
i. Saliva is more alkaline
ii. Higher concentration of calcim &
phosphate in saliva
iii. High mucous content
iv. Longer & curved duct
v. Flow against gravity

 Stone in duct can be palpated

bimanually in floor of mouth & can
even be seen if sufficiently large

 Diagnosis - presence of a tense

swelling below the body of the
mandible, which is greatest before or
during a meal and is reduced in size
or absent between meals
 Enlargement of the Submandibular Lymph
Nodes & Swelling of the Submandibular
Salivary Gland

 commonly enlarged as a result of a

pathologic condition of the scalp, face,
maxillary sinus, or oral cavity

 One of the most common causes of painful

enlargement of these nodes is acute infection
of the teeth
 Surgical Approach to Submandibular
Gland :
• Incision placed 2-4 cm below the
lower border of mandible to
preserve the marginal mandibular
nerve (branch of facial nerve)
 SUBLINGUAL GLAND
 Smallest salivary gland weighing 2-4gm

 Lies beneath the mucous membrane

(sublingual fold) of the floor of the
mouth, close to the frenulum of the
tongue

 Has both serous and mucous acini

 Several ducts : 5-15 in no. (of Rivinus)

from superior portion of gland either
secrete directly into floor of mouth or
empty in Bartholin’s Duct that continues
into Wharton’s Duct
 Nerve Supply :
• Parasympathetic –
secretomotor
preganglionic – facial
nerve via chorda tympani
& post-ganglionic – via
lingual nerve

• Sympathetic –
sympathetic nerves
innervating the gland
travel from cervical
ganglion with facial
artery
 Arterial Supply :
• Supplied by submental &
sublingual arteries
(branches of lingual & facial
arteries respectively)

 Venous Drainage :
• Corresponds to arteries

 Lymphatic Drainage :
• Drained by submandibular
lymph nodes
Structures at risk during dissection of gland

 Submandibular duct (lies superficially in the floor) & lingual nerve (travels
inferior to duct before entering the tongue)
 Sublingual artery & vein (lies medial to sublingual gland)
 Ranulas
 Cysts or mucoceles of sublingual
salivary gland

 Can exists either simply within

sublingual space or plunging
posteriorly to mylohyoid muscle
into neck

 Simple ranula – appears as bluish

non-tender mass in floor of mouth
& may either be a retention cyst or
an extravasation pseudocyst

 Plunging ranula – appears as soft,

painless, cervical mass & is always
an extravasation pseudocyst
 EVALUATION OF SALIVARY GLANDS
 Symptoms are non-specific

Pt. comes with complain of swelling, pain, xerostomia, foul taste & sometimes
sialorrhea (excessive salivation)

Enlargement of major or minor salivary glands, most commonly the parotid or

submandibular, may occur on one or both sides

Parotitis typically presents as preauricular swelling, but may not be visible if deep
in the parotid tail or within the substance of the gland

Submandibular swelling presents just medial and inferior to the angle of the
mandible

Salivary gland swellings are single, larger & smoother than that of lymphatic origin
 Radiologic and Endoscopic
Examination of the Salivary Glands :

1. Sialography –
• relies on the injection of
contrast medium into glandular
ducts so that the pathway of
salivary flow can be visualized
by plain-film radiographs
• most common indication for
sialography is the presence of a
salivary calculus
• should not be performed when
the patient has an acute
salivary gland infection, has a
known sensitivity to iodine-
containing compounds
2. Computed Tomography (CT) –
• Used to assess the parotid and
submandibular glands
• Advantage of CT imaging is the
two-dimensional view of the
salivary glands, which can
elucidate relationships to
adjacent vital structures as well
as to assess the draining
cervical lymphatics
3. CT- sialography –
• Combination of CT & sialography for
difficult cases

4. Magnetic Resonance Imaging (MRI) –

• provides better contrast resolution,
exposes the patient to less harmful
radiation, and yields detailed images on
several different planes without patient
repositioning
• especially used in discriminating
between deep lobe parotid tumors
• inferior to CT scanning for the detection
of calcifications and early bone erosion
• chronic inflammation of the salivary
glands and calculi are not indications
for MRI
5. Sialendoscopy –
• minimally invasive
technique that inspects
the salivary glands using
narrow-diameter, rigid
fiberoptic endoscopes
• lacrimal probes are used
to gently dilate the
ductal orifice and then
the endoscope is
introduced under direct
visualization
• in one setting, at the
time of diagnosis,
treatment and therapy
for benign lesions can be
performed
 CONCLUSION

The surgical anatomy of major salivary glands has many

significant applications in maxillofacial surgery. Understanding
these important anatomic relations- variations enables surgeons
to perform the surgical procedures safely. Knowledge of these
concepts helps us to recognize the problems and complications as
and when they occur and manage them accordingly.
 REFERENCES
 Salivary Gland Disorders By Myers, Ferris – Springer

 Orban’s Oral Histology & Embryology

 Oral Anatomy by Sicher and DuBrul

 Clinical Anatomy By Regions – Richard S. Snell

 Gray’s Anatomy

 Oral & Maxillofacial Surgery by Fonseca

 Textbook of Human Anatomy by B.D.Chaurasia, Vol.3

 Textbook of Human Embryology by Inderbir Singh