Relation of parotid gland

 The gland resembles a three-sided pyramid.

 The apex overlaps the posterior belly of the digastric and the adjoining part of the
carotid triangle.
 Surfaces
 Superior surface or base : related to
 Cartilaginous part of external acoustic meatus
 Posterior surface of TMJ
 Superficial temporal vessels
 Auriculotemperal nerve
 The superficial surface
 a. Skin
 b. Superficial fascia containing the anterior branches of the great auricular nerve.

 c. The parotid fascia which is thick and adherent to the gland .

 d. A few deep parotid lymph nodes embedded in the gland.
 Anteromedial surface
 Grooved by posterior border of ramus
 Masseter
 Lateral surface of TMJ
 Posterior border of ramus
 Medial pterygoid
 Facial nerve branches
 Posteromedial surface
 Mastoid process,with sternocleidomastoid and posterior belly of diagastric
 Styloid process,
 External carotid artery and facial nerve entry
 Borders
 anterior border: separates the superficial surface from the anteromedial
surface . It extends from the anterior part of the superior surface to the apex.
 posterior border: separates the superficial surface from the posteromedial
surface. It overlaps the sternocleidomastoid .
 The medial edge or pharyngeal border separates the anteromedial surface from
the posteromedial surface. It is related to the lateral wall of the pharynx.
Structure within parotid gland
SUBMANDIBULAR GLAND
Superficial Part
 This part of the gland fills the digastric triangle. It extends superiorly deep to the
mandible up to the mylohyoid line.
 Inferiorly: It overlaps stylohyoid and the posterior belly of digastric. It has three
surfaces
Relations:
 The inferior surface is covered by:
 a. Skin
 b. Platysma
 c. Cervical branch of the facial nerve
 d. Deep fascia
Lateral surface is related to:
a. The submandibular fossa on the mandible
b. Insertion of the medial pterygoid
c. The facial artery
The medial surface is related to:
• Anterior part: Mylohyoid, submental branch of facial artery,
mylohyoid nerve and vessel
• Middle part: Hyoglossus, styloglossus, lingual artery, XII nerve
• Posterior part: Stylohyoid, styloglossus, IX nerve.
Deep surface
Relations:
Present in between mylohyoid and hyoglossus.
Laterally – Mylohyoid
Medially – Hyoglossus
Above – Lingual nerve with submandibular ganglion
Below – Hypoglossal nerve
 SUBLINGUAL GLAND
 Anteriorly : the gland of the opposite side
 Posteriorly:deep part of the submandibular gland
 Medially:genioglossus muscle,lingual nerve &submandibular duct
 Laterally:sublingual fossa of the mandible
 Superiorly:mucous membrane of the floor of the mouth
 Inferiorly : mylohyoid muscle

1
 CLINICAL
CONSIDERATION OF
SALIVARY GLAND
Age Changes
 With age, a generalized loss of salivary gland parenchymal tissue occurs.
 Lost salivary cells often are replaced by adipose tissue.
 An increase in fibrous connective tissue and vascular elements also occurs.
 Decreased production of saliva often is observed in older person.
 Chronic inflamation
 Fibrosis
 Dilation of ducts
 DEVELOPMENTAL DISTURBANCES OF SALIVARY
1) Aplasia :
GLAND
The absence of salivary gland is rare although may occur together with other
developmental defect.
Etiology: local disturbances in early fetal life.
Got sequale of xerostomia.
2) Accessory salivary ducts :
Accesory ducts are common and donot require treatment.

Half of patient have accessory parotid ducts.

3) Diverticulic :
Is a pouch or sac protruding from the wall of a duct.
Diverticuli is the ducts of major salivary glands often lead to pooling of saliva and
recurrent sialadenitis.
4) Aberrancy (ectopic salivary gland)
 Situation in which the salivary gland tissue develops at site
where it is normally not found.
 Clinical significance : they may become site for retention
cyst or neoplasm.
5) Atresia
 Congenital occlusion of one or two major salivary gland
ducts.
 Usually submandibular duct in floor of mouth fails to
cannulate during embryological development.
OBSTRUCTION• Common
SALIVARY GLAND
in middle age adults DISORDER
• Mostly male
SIALOTITHIASIS • Submandibular gland(64%),parotid(20%),
sublingual(16%)
 Sialolithiasis is formation of salivary stone in the salivary duct or gland resulting in obstruction
• Asymptomatic
of salivary flow. • Intermittent facial swelling associated with
ETIOLOGY
CLINICAL eating, may be painful or painless
• Medication ,commonly• unilateral
diuretics or
FEATURES
anti-cholinergics
• Dehyration
• Gland palpated-saliva seen at duct orifice-
along with stones(tender)
• Associated with infection- fever,purulent
• hypercalcemia discharge and lymphadenopathy
• Character-annual
• Smoking-reduces salivary proteins growth 1mm per year
• Shape-round to irregular
• Chronic periodontal disease
• Size- 2mm to 2cms

COMPOSITION
Calculus-organic material covered with concentric shells of
calcified material
Crystalline structure- hydroxyapatite and osteacalcium
phosphate
Chemical composition- Calcium phosphate with carbon and
traces of Mg,K,Cl,NH3
MANAGEMENT
 conservative treatment include- oral hydration,
analgesia,sialogues, lemon,milking/massaging
 If infected more- antibiotics
 If persistent frequently- interventional radiology
procedure for 4-5mm diameter
 Surgical procedure- transoral or transcervical
sialolithotomy
 Last option- excision of gland
MUCOCELE (SALIVARY CYST)
Mucocele is bening mucus-containing cystic lesion of minor salivary gland .

CLINICAL FEATURES
Two types
• sites;on the mucosal aspect of the lower lip ,
buccal mucosa, anterior ventral tongue
• Age- children and adult
• Sex ; m=f
a)Extravasation cyst- leakage of fluid from • superficial lesion- small raised vesicle
ducts or acini into surrounding tissue. Due to
like:fluctuant areas,bluish translucent
trauma
• Range from 1 to 2 mm to cms
• Deep lesion-diffuse,firm,painless swelling
b)Retention cyst – narrowed ductal opening
that cant adequately accommodate the exit of
saliva produced causing dialation,swelling.
Due to calculus,scarring,atresia,obstruction
from mucin
 TREATMENT
• Some resolves on their own( rinse mouth with
salt water)
• Corticosteriod injection
• Laser ablation
• Chronic- surgical excision
• Recurrence may occur
RANULA
 Large mucocele present on floor of mouth.
 Cause: trauma,obstructed salivary gland

CLINICAL PRESENTATION:

• Painless
• Slow growing
• Soft movable mass
• Bluish hue colour
• Unilatral in lingual frenum
PLUNGING OR CERVICAL RANULA
• Occur when spilled mucin dissects through the
mylohoid muscle and produces swelling in the
neck.
• Swelling in the floor of the mouth may or may
not visible
• Dumbbell shaped swelling , soft, fluctuant &
painless

• Surgical intervention-
marsupilization
TREATMENT • Intralesional injections
• Recurrence
INFLAMMATORY DISORDERS
A) VIRAL :
- Mumps
- It is an acute contagious viral infection characterized chiefly by unilateral or bilateral swelling of salivary
gland,usually parotid.
- Cause- paramyxoviridae ( RNA virus)
CLINICAL MANIFESTATION
- Spread by droplet infection
- Mainly children- 6-8 years • Headache,chills,moderate fever, pain below ear
• Followed by swelling of earlobe- last 1 week
• Pain on mastication
• Pain and tenderness increases with parotid enlargement
• Swelling remain max for 2-3 days. Subside
• Papilla of parotid duct often on buccal mucosa become reddened and puffy
• Submandibular and sublingual are rarely affected
• 70% bilateral parotid gland involvement
 TERATMENT

• Resolves in 6-10 days

• Fluid maintain
• Means of vaccination(MMR)
BACTERIAL
 NON-SPECIFIC
1) Acute bacterial sialadenitis
 A suppurative process affecting the major gland often than minor gland.
 More common in parotid(lack protection constitute)
 Bacteria;staphylococcus aureus, streptococcus pyogens
RISK FACTOR
CLINICAL FEATURES
• Systemic dehydration
• medication as anticholinergic, beta blocker • tender, red, painful parotid swelling over a
• immunosuppresive few hours
• Chronic disease like liver failure • associated malaise, pyrexia and often
• Renal failure
• HIV regional lymphadenopathy
• Neoplasm • Pain is exacerbated on attempting to eat,
• Sialectasis drink
• Calculi • parotid swelling localized to the lower pole
of gland
• Milking gland- purulent discharge
TREATMENT
• Organism from saliva- culture
• Use broad-spectrum and penicillinase
resistance to non allergens
• Allergic- clindamycin
• If abscess- drain
  Chronic bacterial sialadenitis
 Chronic sialadenitis of major salivary glands is usually a non-specific inflammatory
disease associated with duct obstruction , most often due to salivary calculi,
 Submandibular gland is common
FEATURES
• Unilateral
• Recurrent tender swelling in obstructed area
• Duct orifice may appear inflamed
• Acute exacerbation –may be salty tasting
discharge

Treatement is same as acute sialadenitis

 Recurrent parotitis
 Recurrent parotitis is a rare disorder which can affect children or adults.
 characterized by the rapid swelling of usually one parotid gland
 accompanied by pain and difficulty in chewing, as well as systemic symptoms such as fever and
malaise.
 Each episode of pain and swelling lasts for 3–7 days and is followed by a quiescent period of a few
weeks to several months
 onset is usually between 3 and 6 years, although it has been reported in infants as young as 4 months.

TREATMENT

• treated with antibiotics

• symptoms settle within 3–5 days on such a regimen.
• recurrent episodes are so frequent that prophylactic antibiotics
are required for a period of months or years.
• Symptoms seem to resolve around puberty
‘Specific infections’ (granulomatous sialadenitis)
 Swelling of the salivary glands may occasionally be caused by mycobacterial infection, cat-scratch
disease, syphilis, toxoplasmosis, mycoses, sarcoid, Wegener’s and other granulomatous disease.

Allergic sialadenitis
A variety of potential allergens causing acute parotid swelling have been identified. Some foods, drugs
(most frequently chloramphenicol and tetracycline), metals such as nickel and pollens have been
incriminated.
HIV-associated sialadenitis
 Chronic parotitis in children is almost pathognomonic of HIV infection.
 HIV-associated sialadenitis is very similar to classical Sjögren’s syndrome.
 HIV-positive patients has multiple parotid cysts causing gross parotid swelling and significant facial
disfigurement.
 On imaging with CT or MRI the parotids have the appearance of a Swiss cheese, with multiple large
cystic lesions
 The glands are not painful and there is no reduction in salivary flow rate.
Sialadenitis of minor salivary glands
 Stomatitis nicotina is a chronic infl ammatory disorder of the minor salivary glands of the
palate, seen in heavy smokers.
 appearance is of multiple small target lesions in which the central opening of the gland is infl
amed and bright red.
 Acute necrotizing sialometaplasia is an unusual condition.
 occurs only on the hard palate in the molar region with heavy smokers.
Auto-immune
Sjogren’s syndrome:(sicca disease)
Sjögren’s syndrome is an autoimmune condition causing progressive destruction of the salivary and lachrymal
glands.
Classical traid:
Keratoconjunctivitis sicca, xerostomia, and rheumatoid arthritis
The charachtaristic feature is progressive lymphocytic infiltration acinar cell destruction and proliferation of duct
epithelium.
Primary Sjogren’s syndrome Secondary Sjogren’s syndrome
Xerostomia Primary features+
Dryness of eye SLE, polyarthritis nodusa
Scleroderma rheumatoid arthritis
CLINICAL FEATURES
Etiology
• Female>male
• Autoimmune disorder
• Age=>40years
• Other various cause: hormonal, genetic,
• Presentation;
infection or combination
• Xerostomia, xeropthalmia, arthralgia
• Infection like : CMV, EBV, Paramyxovirus
• Painful burning sensation in oral mucosa
• Lymphadenopathy is twice common in primary
• Primary Sjogren;s symptom; parotid
enlargement,purpura,myositis,kidney involve

Radiographic feature
• Shows cheery blossom or branchless fruit laden tree

• Sialography reveals the progressive damage from punctate

sialectasis to total parenchymal destruction leaving no more
than a grossly dilated duct
Treatment
• Xerostomia- salivary subtitites, artificial saliva
• Kerato conjunctivitis- ocular lubricants,artificial
tears
• Dental caries- fluoride application
• Gland enlargement- surgery
FUNCTIONAL DISORDER

Xerostomia(dry mouth)
Most common clinical manifestation of salivary dysfunction, involving a reduction
or absence of salivary secretion.
CLINICAL FEATURES
• Normal Dependingsaliva
uponflow;whole
severity: resting: O.3-O.4ml/min stimulated:1-2ml/min
• Fissures and ruptured of the lips
• Dysgeusia ETIOLOGY
•• Bilateral swelling
Anxiety, depression
•• Presence of milky saliva draining from glandular ducts
Duct calculi
•• Dry,pale,ruptured and lusterless mucosal membranes
Sailadenitis
•• Problems with food ingestion,frequent consumption of
Drug therapy:
fluids during meals
diuresis,bronchodilators,antihistamines
•• Burning mouth syndrome
Sjogren’s syndrome
•• Increase acidity- caries,erosion
Radiotherapy of head and neck
•• Diffuculty in dentures
Surgery of gland
• Postmenopausal woman
 TREATMENT
• Drinking water time to time
• Artificial saliva
• Sugarfree gums,lozenges,mints
• Oral care products: mouthwash,gels,sprays
• Monitorining of teeth,gingiva and mucosa
• Avoid alcohol,ciggrates,caffine, spicy food
• Medication: pilocarpine, cevimeline (fda)
Artificial saliva ????
 Severity scale of drooling
Sialorrhoea (hypersalivation)
• Dry – never drools
 Means drooling
• Mild – only lip wet
 Some drugs and painful lesions in the mouth increase salivary fl ow rates.
• Moderate- lips and chin wet

•common in neuromuscular dysfunction, toxins, GERD, Anatomically dysfunction
Severe –clothing soiled
 Some medication like anticonvulsants, pilocarpine,tranquilizers
• Profuse –clothing, hands,and tray
moist wet
 TREATMENT
• Speech therapy: eating and drinking skills,positioning,oral
facial facilitation
• Medication –Robinul,cevimeline(evoxac),pilocarpine
• Surgical intervention-laser surgery
• Radiotherapy-severe
TUMORS RELATED TO SALIVARY GLAND
 FEW BENING TUMORS
CLINICAL FEATURE
1) Pleomorphic adenoma
• M:F = 3:2, 4TH TO 6TH DECADE
Most common salivary gland tumor.
• MAJOR GLAND:Lower pole of superficial
 Parotid 84%, about 50% all intraoral minor salivary gland
lobe
 • 5% malignant transformation
MINOR GLAND-Hard palate, upper lip
• Slow growing,firm,painless,round to oval
shape TREATMENT
• •Mobile expect in hard palate
For parotid-superficial paratidectomy preserving facial
nerve
• For submandibular-complete excision
• Intraoral tumor-extracapsular excision including rim
of surrounding tissue
Warthin’s tumor
 Also known as cystadenolymphoma
 6% epithelial tumor of salivary gland.

CLINICAL FEATURES

• SITE: Almost parotid gland

• Age: 6th to 7th decade
• Sex=men >female
• Soft to firm mass,slow growing
• Painless, hardly 3-4 cm

TREATMENT
• Surgical incision
• Radiation therapy-reduce mass
• Recurrence and malignant transformation rare
Monomorphic adenoma

 Bening salivary gland tumors composed predominantly of

epithelium with no evidence of mesenchymal tissue.
CLINICAL FEATURE
• Rare tumor in parotid and salivary gland
• A submucosal nodular mass
• Freely mobile firm to slightly compressible
• Normal color of overlying tissue

TREATMENT
Extracapsular surgical excision
MALIGNANT TUMOR
1) Muco epidermoid carcinoma
 Most common malignant tumor
 Cause: radiation, lipoidal instillition , foreign body
• Age- 3rd-5th decades
• CLINICAL PRESENTATION
Sex – female predilection
• Site: parotid gland, palatal , mucosal

a)Low grade
• Slow growth,painless,stimulate pleomorphic
adenoma
• Size->5cm,encapsulated,filled with viscid, mucoid,
mucus discharge
• Minor gland- bluish or red purple,fluctuant,smooth
b) surface
High grade
mass
• Rapidly growing, doesnot produce pain
• If facial nerve involve- trismus,drainage from
ear,dysphagia
• Metastasis – Regional LN lung,breast
 TREATMENT

• Early stage of tumor- subtotal parotidectomy with preserving

of facial nerve
• Advanced- total removal of parotid, submandibular
• Minor gland- usually by surgical excision
• Radical neck dissection-metastasis high grade tumors
 2) Adenoid cystic carcinoma
 Aggressive neoplasm with recurrence capacity
 Clinical presentation
Age- 5th-7th decade
 Sex – slightly prevalent in female
• Slow growing, firm on palpation

• Pain
Sitefixation
– bothtomajor(parotid>submandibular), minor
underlying structure along with local salivary gland
invasion.
• Facial nerve paralysis,anesthesia paresthesia in severe condition
• Palatal tumor ulcerated

TREATMENT
Wide surgical excision
Post-operative radio-therapy (tumor cells are
radio sensitive)
REFRENCES: Oral and maxillofacial surgery Jonathan
Pedlar, Jhon W. Frame) 2nd edition
Tencate’s Oral Histology