Surgery of The Salivary
Glands
By
Mahmoud Abdelnasser. M.D.
Prof. of General & GIT Surgery
Tanta Faculty of Medicine.
Salivary glands
Surgical Anatomy of Parotid Gland
Position: under skin & infront and below the ear.
It lies within the parotid fascia (investing layer of
the deep cervical fascia).
Baunderies:
Anterior :(maseter ms, ramus of mandible, med.
pterygoid ms.)
Posterior :( mastoid process, st.mastoid ms.)
Superior : (Ext. audiotry meatus , T.M.Joint)
Inferior: ( St.mastoid ms., posterior belly of diagastric ms.)
Lateral :( investing layer of deep c. fascia,
platesma, &skin ).
Medial : (invest. layer of deep c. fascia, styloid
process, int .jug. V. int. carotid A., pharynex)
Parotid Duct (Stenson duct )
It is 2-3 m.m. in diameter .
Begins deep and behined the angle of
mandible .
Passes through the gland receiving
interlobular ducts as it goes.
Passes lat. To masseter ms. Then pierce
the buccinator , and forward submucosal
to open in the mouth cavity opposite the
upper second molar tooth.
Structures Traversing Parotid Gland
Fascial nerve:
Emerges from stylo-mastoid foramen.
Entres the gland through post.-infer. Border.
After 1cm. It divides into five branches
cervical
Mandibular
Maxillary
Zygomatic
Temporal
Arteries
Ext. carotid art. Enters the inferior surface
Of the gland where it divides into :
maxillary artery.
superficial temporal artery.
veins
Super.temporal v. joins the maxillary v. to
form the retro-mandibular v.
Retro-mand. V. divides into ant. Branche
which join the ant. Fascial v. to form the
common fascial v. & post. Br. Which join
the post. Auricu. V. to form ext. j. v.
The arrangement of structures Inside the
parotid gland
1. The fascial nerve
and its branches.
2. Retro-mandibular
vein.
3. Arteies (external
carotid artery,
maxillary a.
super.temporal a.)
Nerve supply of the parotid gland
Parotid fascia ( G.auricular n. C.2 )
Secreto-motor (parasympathatic) by the
auriculo-temporal n.
Sympathatic n.(superior cervical symp.G.)
Surgical Anatomy of The Submandibular
Salivery Gland.
Lies within the
submandibular
triangle.
It is composed of
superf. Part related to
mylohyoid ms.
The deep part related
to hyoglosus ms.
Upper part lies in
concavity of the
submand. Fossa.
Lingual nerve is enclosed in the fascial sheath of
the gland at its upper pole.
Submandibular duct lies
below the nerve at the
upper of the gland.
Submandibular duct
(Wharton”s duct)
5 cm. long.
Runs forward from the
deep part of the gland to
enter the floor of the
mouth on a papilla beside
the frenum of the toung.
Incision must be 3-5 cm below the ramus of the
mandibule to avoid injury of :
1. Cervical br. Of
fascial n. which
innervate
platysma.
2. Mandibular br. Of
fascial n. which
innervate ms. Of
lower lip.
Investigations
1. Plain X-Ray.----Salivery calculi.
2. Sialography: Lipidol or Hypaque is
injected through duct system it shows:
Obstruction
Dilatation( duct ectsia).
Narrowing or stricture.
Fistula.
Abscess cavity.
Position and size of salivery neoplasm.
3. U/S. :(single or multiple, cystic or solid).
4.MRI
5.CAT scan.
6.F.N.A.B.Cytology.!!
Generalized Parotid Enlargement
1. Viral parotitis (mumps):
Paramyxovirus.
Pancriatitis ( abdominal pain ).
Orchitis.
Encephalitis.
The gland is rapidly enlarged, uni. Or bilateral.
There is acinar cell necrosis and lymphocytic
infiltration.
Acute suppurative parotitis
Follow major surgery (Dehydration).
Bad oral or dental hygiene.
After radiotherapy of the face.
Sjogren’s syndrome.(gl. Destruction).
Clinically:
Usually Unil.
Enlarged, tender,painful gland.
Pressure over gland leads pus discharge from the
p.duct opening opposite 2ed molar tooth.
Fever.
Trismus.
Unrecognized--- abscess formation.
Treatment.
Improv. Of G. condition of patient.
Broad sp. Anti-biotic.
Rehydration of post op. patients.
Good oral hygene.
Soft dite.
Massage the gland gentally.
Once abscess has formed I. &D.
Sialectasis
Rec. infections of dilated acini.
Common in trympt player, glass blower.
Clinically:
If you ask the patient to make his lips
purssed tightly and the nose obstructed,
the gland will inflate like ballon.
Plain X-Ray:
Shows ducts and acini outlined by air.
Sialography: ducts& acini are grossly
dilatated.
Treatment
Treatment of any dental disorder.
If the gland is grossly disorganized
and both pain and recurrent infection
is sever superficial parotidectomy is
essential.
Parotid Calculi
Is rare because secrection is serous.
Composed of Ca.phosphate with less degree
of Ca. carbonate.
If obstruction and infection are present it lead
to supp.parotitis.
Submandibular G. Calculi
Is common, vicised secretion, independent
drainage.
Sailography:
Shows calculi in the duct.
Salivary caculi.
Treatment
1. Calculi within the duct may be
removed via the floor of the mouth.
2. Calculi within the submand. gland
(submandibular saliadenectomy.)
3. Parotid calculi within the duct can
be reached from the oral cavity.
4. Calculi within the gland (superficial
parotidectomy).
S.M.G. Stone
Causes of duct obstruction of a major S.G.
1. Salivery calculi.
2. Stricture of the duct wall.
3. Oedema.
4. Fibrosis of the papilla.
5. Pressure on the duct from adjac.
Mass.
6. Invasion by malignant neoplasm.
Causes of papillary stenosis:
1. Trauma from denture.
2. Irritation from sharp tooth.
3. Bite of the check.
Repeated trauma leads to fibrosis
&setnosis.
Treatment
Papillotomy ,and suturing of duct lining to
oral cavity.
Sal. Glands Neoplasm
Incidence :
75% arise from parotid gland.
80% are benign .
80% of the benign are pleomorphic
adenoma (mixed s. tum.).
15% of neoplasm arise in submand.s.gl.
60% are benign.
95% of benign are pleomorphic adenoma.
10% of neoplasm occurs in the minor s.g.
Classification of S.G.Neoplasm
I. Epithelial tumours:
A. Adenoma.
Pleomorphic adenoma (mixed s. tu.).
Monomorphic adenoma.
a) Oxyphil adenoma.
b) Adenolymphoma.
c) Other types.
B. Muco-epidermoid tumour.
C. Acinic cell tumour.
D. Carcinoma:
1. Adenoid cystic carcinoma.
2. Adeno-carcinoma.
3. Epidermoid carcinoma.
4. Undiff. Carcinoma.
5. Carcinoma of pleomorphic adenoma.
Pleomorphic adenoma (mixed S.T.)
It contains :
Epithelial cells (from the duct).
Mucoid material (myxomatus apperance).
Cartilage.
Cystic changes.
Clinically:
Slowly growing tum.
Firm or elastic.
Lobulated mass.
It is classified as benign or locally
malignant tum., as it tends to penetrate
the thin capsule of compressed gland
substance & connective t.
Tumour lobules are attached only by a
narrow neck of tissue which may extend
beyond the main mass.
So simple enculation will leave residual
neoplasm and result in multicentric
recurrance.
After 20-30 years it may transform to
carcinoma.
Pleomorphic adenoma
2. Monomorphic adenoma.
a) adenolymphoma:
Benign neoplasm.
Composed of double layered epithelium
which lines cystic space .
The inner layer is columnar and folded
inwards to show papillary growth.
clinically
Slowly growing soft, cystic swelling.
Usually bilateral.
Usually towards the lower pole of the
gland.
10% of parotid tumour.
Hot spot with Tc99 and not cold like other
malignancies. ( preoperative diagnosis is
possible without biopsy).
carcinoma
1.Adenoid cystic carcinoma.
Myoepithelial cells.
Duct epithlial cells.
The commonest early symptom is
pain.
There is area of anaethesia of the
skin.
Paralysis of mus. Due to
involvement of related nerves.
2. Mucoepidermoid carcinoma
Sheets and masses of epidermoid cells&
clefts and cystic spaces lined mucous
secreating cells.
Cartilage and myxoid appearance.
Locally malignant & invade local tissue to
a limited degree.
Some are aggressive and grow rapidly &
occassionaly send metastasis to L.N., lung
and skin
3. Acinic cell tumour
Mostly in the parotid.
Its cell resmbleing serous acini.
Soft, cystic.
Locally malignant.
Like mucoepidermoid tu. May send met astsis.
4. Adenocarcinoma.
5. Epidermoid carcinoma.
6. Undifferantied carcinoma.
All these tumours show cells
arrangement resemble various
glandular elements.
They are subdivided according to the
predominant cell.
Clinical signs of malignancy
Hard.
Fixation.
Pain.
Resorption of adjacent bones.
Anaethesia of skin and mucous me.
Paralysis of adjacent mus.
Fascial n. irritability, followed by
paraslysis.
Limitation of jaw movement due to mus.&
bone invasion.
Surgical treatment of salivery neoplasm
I. slow growing parotid T.
)pleomophic adenoma, Wathin T.,
Muco-epidermoid T.
Are treated by superficial parotidectomy.
The main trunk of fascial is identified.
Each branch is identified .
If any branch is actually penetraing the
tumour it must be sacrifised and replaced
by a nerve graft.
II. Slow growing submandibular G.
Excision of the whole gland with the
adjacent tissue. ( submandibular
saliadenectomy).
Coserving the lingual& hypoglossal nerve.
4. Treatment of neoplasm which present
with clinical signs of malignancies.
Whenever signs of malignancy are present radical
excision is recommended.
Parotid:
Total protidectomy with sacerifization of the
fascial nerve.
Nerve graft from G.auricular n.
Most salivery G.T. are relatively radio resist.
Radical excision of parotid is limited by int.
carotid a.
Excion of mandibule and temporal bone may be
required.
Submandibular G. malignancies.
Radical excision of :
Sub. M. s. g.
Mandibule.
Toung.
Neck L.N. Dissection
Sjogren’s syndrome.
Clinical triad of :
1.Dry mouth (xerostomia).
2.Dry eys (kerato-conjctivitis sicca.)
3.Rheumatoid arthritis.
Some syst. Diseases (S.L.E.&
scleroderma ) have been recognized
pathology
S.Gl. & Lacremal G. are infiltrated by
lymphocytes + Acini are destroyed.
Epith. Ducts become hyperplastic,
forming casts within the lumen
blocking ducts.
Stricture and ascending infection
complicate the condition.
Hypergamma-globinaemia.
Auto –antibodies
complications
Sever dryness of the mouth leads to
dental caries and falling of teeth.
Lips tounge palate stick together.
Tounge become cracked, glossitis,
stomatitis and monilial infection.
Diffuse enlargment of s.g. must be
D.D. from malignancies.
Von-Mikulicz Disease
Described Triad :
1. Symetrical enlagment of S.Gl.
2. Narrowing of the palpe. Fish. Due to
enlargment of lacrimal gland.
3. Dryness of the mouth.
It is an auto-immun.D. & a variente of
Sjogern’s syndrome.
Treatment
Dry eyes : methyl cellulose eye drops.
Meticuls oral hygene, methyl celluolose
mouth wash, to keep the mouth moist.
Steroid & immunosupressive drugs.
Radiotherapy to decrease the size of gland
