Salivary Gland Disorders

Diagnostic aids I. Clinical history A. Past and present medical history

To determine any medical conditions or medications that is Examples: patient who received radiotherapy for a head and These two examples associated with salivary hypofunction. It may be caused by non-neoplastic as well as neoplastic The location and the incidence of occurrence of the swelling are

known to be associated with salivary gland dysfunction.

neck malignancy or patient who taking a tricyclic antidepressant. B. Swelling

processes.

critical in the differential diagnosis. Intermittent swelling

If associated with eating, it suggests an obstruction and the

swelling will subside between meals if the gland is not infected. Persistent swelling

Caused by tumors or a generalized process such as sjeogrens

syndrome, diabetes, alcoholism.etc. Unilateral swelling

Results from localized processes such as infections, tumors or

mechanical obstruction. Bilateral swelling

Associated with a systemic condition such as mumps or an

endocrine dysfunction.

C. Pain

Pain and fullness of the gland, related only to eating suggest Infection and inflammation produce a more persistent pain not

obstruction.

related to eating. D. Salivary flow

Decreased or increased. Commonly caused by:

1. Drugs. 2. Systemic diseases (Sjeogrens syndrome). 3. Secondary to radiation therapy.

Xerostomia

Sialorrhea (increased salivation) Commonly caused by:

1. Increase in flow rate 2. Secondary to an inability to swallow normal secretions. 3. Emotional or psychogenic factors. 4. Chronic neurological disorders (Parkinsons disease, cerebral

palsy, mental retardation ... etc.) II. Physical examination: A. Inspection 1) Size

Diffuse enlargement of a single gland suggests inflammatory Enlargement of multiple glands suggests:
1. 2.

process or a tumor.

Sjeogrens syndrome. Metabolic disorder (alcoholic cirrhosis).

2) Site.

In the preauricular and Submandibular regions parenchymal

glandular involvement must be distinguished from regional lymph node involvement. 3) Shape. 4) Symmetry. 5) Overlying skin / mucosa. 6) Surrounding edge well/ ill defined. 7) Inspection of the duct orifices for pus or calculus. B. Palpations 1) Tenderness. 2) Temperature. 3) Consistency 1. Firm or hard (tumor). 2. Soft or rubbery (possible enlarged lymph node). 4) Fluctuance. 5) Mobility of the swelling relative to the under & overlying tissues.
1.

Intra-oral minor salivary gland lesions usually appear on the

posterior palate.

Movable benign or fixed malignant.

6) Regional L.N status. 1. Palpable. 2. Tenderness. 3. Consistency. 4. Mobility.

7) Saliva collection Salivary flow rates can be calculated from the individual major salivary glands or from a mixed sample of the oral fluids, termed whole saliva.

Whole saliva is the mixed fluid contents of the mouth. The main methods of whole saliva collection include the Unstimulated whole saliva flow rates of < 0.1 mL/min and

draining, spitting, suction, and absorbent (swab) methods. stimulated whole saliva flow rates of < 1.0 mL/min salivary hypofunction. 8) Palpation of the involved salivary gland bilaterally Bidigital and/or Bimanual ( palpation) 1. Gland
Consistency. Massaging the gland and looking at the duct orifice duct

purulence & flow of saliva. 2. Duct

Palpable stone, Site, size

9) Check the integrity of the nerves:

Facial n., lingual nerve (tongue taste sensation), hypoglossal

nerve (Tongue mobility) for malignant infiltration of nerves.

III. Preoperative diagnostic screening: 1. Plain radiographs: Advantages: 1- Used to demonstrate the presence of calculi. 2- Used as comparative documentation after removal of the stone. Disadvantages:
o No information about ductal system and soft tissue.

1- Occlusal view
o It is used for detection of calculi in the floor of mouth (Whartons

duct). 2- Periapical film

o Detect a stone in the parotid duct by placement against the inside of

the cheek. 3- Puffed cheek view

o For calculi of the parotid duct.

2. Computerized tomography (CT) scanning: Indication

1.

The best choice for examination of masses of the salivary Study the diffuse non-inflammatory enlargement of the salivary Detection of S.G calculi especially in case of posteriorly

glands.
2.

glands.
3.

located submandibular gland duct. CT Sialography

1.

Limited in evaluating ductal system unless combined with

sialography.

3. Magnetic resonance imaging (MRI): Equal or better than CT in: 1. 2. 3. 4. 5.

6. 7.

No contrast medium. Less radiation. No need for ductal cannulation. Can be used in acute inflammation. Detection of a lesion or mass. Minimal artifact from dental restoration. Can be performes with Sialography MRI Sialography.

4. Radionuclide scans (Scintigraphy):

Scintigraphy is the only salivary imaging technique that The most common isotope used is technetium 99. Uptake of the isotope by the gland increase in case of acute Neoplasms arising within the salivary glands do not

provides information on the functional capabilities of the glands.

inflammation and decrease in case of chronic inflammation.

concentrate Tc 99 except Warthins tumor and oncocytoma, which retain the Tc 99 because they do not communicate with the ductal system, and they appear as areas of increased activity on static images. Indication:
1. Determination of space occupying lesions 2. Evaluate the salivary function of the glands. 3. Evaluation of patients when sialography is contraindicated or

cannot be performed (such as in cases of acute gland infection or iodine allergy). Advantages 1. Dynamic and minimally invasive.
5

5. Ultrasonography: Advantages: 1. Fast. 2. Economical.

3. Non-invasive. 4. Simple.

Indication: 1. Detect stone 2mm.

2. Detecting space occupying lesions. 3. Differentiate a cystic lesion from a solid mass. 4. Differentiate intrinsic lesion from extrinsic mass.

5. Evaluation of masses occurring in the submandibular gland & the superficial lobe of the parotid gland. 6. Biopsy
1. Helpful in the diagnosis of Sjeogrens syndrome. 2. The most common suggested procedures are: a.

Excision biopsy should be done if the diagnosis

remains inconclusive after the investigation from the intraoral minor salivary gland (lower lip).
b.

Incisional biopsy should not be done because it will Fine needle aspiration biopsy (FNAB). FNAB is a safe, quick, and reliable procedure. Can immediately differentiate cystic, inflammatory, reactive, and neoplastic (benign or malignant) lesions.

seed tumor cells into the surrounding tissues.

c.

3. Fine needle aspiration biopsy (FNAB):

7. Laboratory investigation:

Laboratory blood studies are helpful in the evaluation of dry The presence of nonspecific markers of autoimmunity, such as antibodies, rheumatoid factors, elevated

mouth, particularly in suspected cases of Sjgrens syndrome. antinuclear

immunoglobulins, and erythrocyte sedimentation rate the definitive diagnosis of Sjgrens syndrome.

Serum amylase salivary gland inflammation.

8. Sialography: Definition: Sialography is the radiographic visualization of the salivary gland following retrograde instillation of soluble contrast material into the ducts. Contrast medium: (both contains high percentage of iodine)

Oil based High viscosity. Difficult to inject discomfort. Long time for elimination. Allows for maximum opacificaton of the ductal and acinar structures. E.g. lipiadol.

Water soluble Low viscosity. Easy to inject discomfort Shorter elimination time. Decreased radiographic density and poor visualization of peripheral ducts. E.g. (Hypaque and renografin).

Appearance
1. The

normal ductal architecture has a leafless tree

appearance. 2. Non opaque sialoliths appear as voids. 3. Sialectasis is the appearance of focal collections of contrast medium within the gland, seen in cases of sialadenitis and Sjgrens syndrome.

Indications: 1. Detection of ductal obstruction, stenosis &stricture 2. The presence and the size of the tumors 3. Detection of salivary fistula Therapeutics uses:
1. 2.

CM contains Iodine (bacteriostatic effect). Drainage of ductal debris & mucus plug. Sensitivity of iodine.

Contraindications: 1.
2. Acute infection (ruptures the already inflamed gland + the

injection of contrast material might force bacteria throughout the ductal structure and worsen the infection).
3. Thyro-toxic patient.

Advantages
1. Detection of radiolucent sialoliths. 2. Functional evaluation of the gland. 3. Detection of the position and size of a neoplasm. 4. Fistulae and abscess cavities can be displayed.

Disadvantages: 1. Invasive.
2. Requires iodine dye.

9. Sialoendoscope Indications: Limitations:

Diagnosis of S.G pathosis either in duct or parenchyma Acute infection (Painful and may perforate the duct lumen). Tortuous duct and distorted branching.
5

 Equipments:

Too narrow duct. Too deep and large stone. Salivary probes blunt to avoid perforation of duct. Conical Dilator Gentle dilatation of duct orifice. Source of light & high resolution camera. Irrigation Channel easy insertion, dilatation, cleansing & Hollow Rigid Bougie Dilatation of gross stenosis. Disposable Balloon Dilator inserted (deflated) then Retrieval wire basket for Stone retrieval. Mini-Forceps for Stone retrieval. Laser Fiber Sialolithotripsy fragmentation of calculus.

heat generation.

inflation to dilate the stenosis.

Steps:
1. In Case of duct Stenosis:

Insert balloon through working channel and inflation is done

inside. Or insert hollow bougie in severe stenosis.

2. In Cases of Stone or Calculi:

If < 3mm Hold it by forceps or wire Basket. If > 3mm, irregular and stuct to the duct walls Laser

beam is used for fragmentation, then fragment is held by miniforceps or wire Basket.

Classification of the salivary glands diseases Developmental

Aplasia (agenesis), atresia. Aberrancy (Latent bone cyst).

Inflammatory Viral (Viral sialdenitis)

Mumps. Coxachie A. Non-specific

1. 2. 3.

Bacterial Acute bacterial sialdenitis. Chronic bacterial sialdenitis. Necrotizing sialometaplasia. Radiation sialadenitis Tuberculosis. Actinomycosis. Sarcodosis.

4.

Specific
1. 2. 3.

Cystic

Retention cyst. Extravasation cyst. Ranula. Latent bone cyst Sialolithiasis. Stenosis & stricture.

Obstruction

Autoimmune

Sjeogrens syndrome.

Functional disorders: Metabolic

xerostomia sialorrhoea (ptyalism) Malnutrition (kwashiorkor). Alcoholic cirrhosis. Endocrine (Diabetes mellitus.) Benign
1.

Neoplastic Mixed tumor (pleomorphic adenoma). Monomorphic adenoma. warthin's tumor (cystadenolymphoma, papillary Oncocytoma (oxyphilic asenoma). Basal cell adenoma. Myoepithelioma. Sebecious adenoma. Intraductal adenoma. Mucoepidermoid carcinoma. Adenocystic carcinoma. Polymorphous low grade Adenocarcinoma. Acini cell carcinoma. Carcinoma explemorphic adenoma.

2.
3.

cystaenoma lymphatosum).
4.

5. 6. 7. 8.
1.

Malignant 2.
3.

4. 5.

1. Developmental conditions
Salivary Gland Aplasia
1. Congenital absence of major salivary glands. 2. Parotid gland agenesis has been reported in conjunction with several

congenital

conditions,

including

hemifacial

microstomia,

mandibulofacial dysostosis, and cleft palate.

3. Cl. Presentation (Xerostomia, Mucositis, Glossitis,Caries).

4. Diagnostic Approaches : Sialometry (flow rate)

< 0.1 ml/min (unstimulated). < 0.5 ml/min (stimulated).

Scintigraphy.

2. Cystic Conditions
MINOR SALIVARY GLANDS The mucocele

Swelling caused by the accumulation of saliva at the site of a Classified into:

1.

traumatized or obstructed minor salivary gland duct. Extravasation Mucocele: traumatic injury salivary

leakage into the surrounding tissue granulation tissue encapsulation

2.

Retention Mucocele: Represents dilatation of salivary

excretory duct due to obstruction by a mucous plug or sialolith formation (FOM, palate)

Ranula 1. Mucocele that occurs in the floor of the mouth arising from sublingual salivary gland

The site: the lower lip in young people, buccal mucosa. Etiology: minor trauma. Clinically:
1. Superficial lesion: small bluish translucent, smooth, fluctuant

vesicle.
2. Deep lesion: a firmer vesicle with the same color of normal

mucosa.

Treatment:
1. Simple removal of the cyst leads to recurrence of the

mucocele 15-30%.
2. A vertical incision over the lesion with removal of the

underlying minor salivary gland.

3. In recurrent cases, a CO2 laser is used to ablate the surgical bed

and any underlying salivary tissue. 4. The wound is left open to heal by secondary epithelialization in these cases. SUBLINGUAL GLAND The Ranula

Its the accumulation of saliva beneath the thin mucous

membrane of the floor of the mouth due to obliteration of sublingual gland duct. Clinically:
1. 2.

Soft, compressible, painless bluish mass enlarge slowly. May raise the tongue and interfere with the speech.

Etiology: Extravasations of saliva secondary to trauma. Plunging ranula:

The mylohyoid muscle does not always form a complete diaphragm for the floor of the mouth, and leakage of saliva below the mylohyoid can allow the lesion to present in the upper neck. Treatment A- Marsupialization Recurrence rate of 60-90 %
B- The excision of the sublingual gland.

Initially, Whartons duct is cannulated so that it can be

identified and protected during the dissection. PAROTID GLAND The True cystic lesions affecting the parotid gland are: 1. Hereditary polycystic disease. 2. Parotid duct cysts. 3. Retention cysts. 4. Lymphoepithelial cysts. Lymphoepithelial cysts:

Solitary masses within the parotid that is clinically One of the manifestation of acquired immunodeficiency Etiology:
1.

indistinguishable from parotid tumors.

syndrome (AIDS). Inflammation causing proliferation of epithelial remnants

within parotid lymph nodes.

Treatment:
1.

Superficial parotidectomy with preservation of the facial Bilateral parotidectomy may be beneficial for cosmetic

nerve is recommended.
2.

reasons.

3. Inflammatory/Reactive Conditions
The parotid gland is most often affected by these conditions. A. Non specific 1. Acute bacterial sialadenitis

A suppurative process affecting the major glands more often than the

minor glands. More common in parotid Pathogens: 1. 2.

3.

Staphylococcus. Streptococcus. Gram-negative bacteria and anaerobes (in hospitalized &

immunocompromised patients).

Predilection for Parotid:

1.

The parotid is more prone to bacterial infection due to its

secretions are serous and thus lack the protective constituents (IgA, lysozomes) seen in mucinous secretions of the other salivary glands.
2.

The submandibular glands may be protected by the high level

of mucin in the saliva, which has potent antimicrobial activity. Pathogenesis

1.

Bacterial sialadenitis occurs as the result of salivary stasis and

subsequent retrograde contamination of the salivary ducto-acinar units by oral flora (Bacterial ascending infection).

2.

Causes

of

salivary

stasis

include postsurgical

setting,

dehydration, medical illness, radiation, aging and sialolithiasis.

3.

Postoperative sialadenitis was f referred to as surgical

parotitis because postsurgery patients often experienced gland enlargement from ascending bacterial infections.
4.

This is due to decrease in salivary flow during anesthesia +

administration of anticholinergic drugs.

Risk Factors for Sialadenitis:

1. 2. 3. 4.

Systemic dehydration (salivary stasis). Chronic disease and/or immunocompromise. Neoplasms (pressure occlusion of duct). Sialectasis (salivary duct dilation) increases the risk for Poor oral hygiene. Calculi, duct stricture.

retrograde contamination.
5. 6.

Clinical presentation 1.
2.

General symptoms; fever. Sudden onset of unilateral or bilateral salivary gland The involved gland is painful, indurated, and tender to The overlying skin may be erythematous. Purulent discharge from Stensens duct Rarely, a cutaneous fistula may occur, with spontaneous

enlargement. 3. 4.
5.

palpation.

6.

drainage of purulent material. Diagnosis 1. Purulent saliva should be sent for culture.

2.

If no response to antibiotics in 48 hrs perform MRI, CT or Needle aspiration of abscess.

ultrasound to exclude abscess formation.

3.

Treatment of Acute Sialadenitis/Parotitis 1. 2. Culture and sensitivity testing (for appropriate antibiotics). Supportive measures

Fluid replacement. Empirical antibiotic and analgesics. Improved oral hygiene. Massage of the gland. Warm compresses. Sialogogues (salivary stimulants).

3. 4.

Failure to respond incision and drainage. Incisions should be placed parallel to facial nerve branches to

avoid injury. Complications of Acute Parotitis

1.

Direct extension.

Into external auditory canal and TMJ. Into the parapharyngeal space airway obstruction,

mediastinitis, internal jugular thrombosis and carotid artery erosion. 2.

3.

Hematogenous spread Dysfunction of one or more branches of the facial nerve.

2- Chronic sialadenitis

It affects the submandibular gland more than parotid gland It may be:
1. Secondary to episode of acute parotitis. 2. Idiopathic or retrograde infection through the duct. 3. Associated with sjeogrens syndrome.

frequently.

1.

Clinical picture Unilateral or bilateral swelling of the gland during meal Intermittent remissions and exacerbations. Ductal dilatation, glandular destruction and finally Treatment Massage of the gland. Sialogogues (salivary stimulants). Treat the predisposing factor such as a calculus or a If conservative measures fail removing the gland. time
2. 3.

scarring of the duct. Conservative treatment

stricture.

3- Necrotizing sialometaplasia

Benign self limiting condition of the oral cavity. It originates from the minor salivary glands of the hard palate,

buccal mucosa, lip or retro molar area.

 1.

Clinical picture: Presents as an ulcer. It is usually painless. The ulcer may be unilateral or bilateral and appears and sharply demarcated. 2.
3.

large, deep

Etiology: Local ischemia (trauma, L.A injury, smoking). Treatment: Self-limiting & heals by secondary intention in 6-8 weeks.

4. RADIATION-INDUCED PATHOLOGY Doses of 50 Gy will result in permanent salivary gland damage (complete destruction of the serous acini and subsequent atrophy of the gland) and symptoms of oral dryness.

Radiotherapy is usually delivered in fractionated doses 5 days

per week for 6 to 8 weeks. Acute effects on salivary function can be recognized within a week of beginning treatments at doses of approximately 2 Gy daily and patients will often voice complaints of oral dryness by the end of the second week. Salivary neoplasm is increased in incidence after radiation exposure. B. Specific inflammation I- VIRAL 1-Mumps (epidemic parotitis)

Non-suppurative bilateral acute sialadenitis of viral origin. It is a contagious disease (Droplet infection). Its incubation period is 2-3 weeks. It affects mostly children at 6-8 years old. The causative virus

1. Mumps paramyxovirus. 2. Coxsackie virus A. 5

3. Echo virus.

Clinical picture:
1. Painful parotid swelling may last 2 weeks.

2. Usually one gland is affected first then the other.

3. The symptoms subside in 3-7 days and recovery occurs within

2-3 weeks.

LABORATORY INVESTIGATIONS: Increase in serum amylase. Complications of mumps:

1.

Other organs (e.g., testes, ovaries, breasts, and pancreas) In adults, orchitis may lead to sterility. It resolves spontaneously in 5-10 days. Symptomatic relief of pain and fever (analgesic Prevention of dehydration is essential by increase fluid

may be affected.
2.

Treatment 1.
2.

antipyretic).
3.

uptake. 2-Cytomegalovirus

Frequently in immune-suppressed patients (e.g., those with

bone marrow transplants, on chemotherapy, or with HIV). II-BACTERIAL 1-Tuberculosis 2It is rare. The infection may be confined to the parotid lymph nodes or SARCOIDOSIS

may affect the salivary gland parenchyma.

It is rare. Patients usually present with bilateral, painless, and firm

salivary gland enlargement.

4. Immunologic disorders
Sjeogrens syndrome Definition Sjgrens syndrome is an autoimmune disease characterized primarily by decreased lacrimal and salivary gland secretions. Clinical features: Triad of: 1. Xerostomia (mouth). 2. Keratoconunctivitis sicca (eyes). 3. A connective tissue disease (usually rheumatoid arthritis). Salivary, mucous and lacrimal glands replacement by a lymphocytic infiltrate causes the classic symptoms of dry eyes, dry mouth and parotid swelling.

Inspection and palpation of the glands reveal bilateral, nonPatients have an increased risk of developing malignant

tender, firm, and diffuse swelling. lymphoma. Two forms:

Primary: involves the exocrine glands only Secondary: associated with a definable autoimmune disease, 80% of primary and 30-40% of secondary involves unilateral or

usually rheumatoid arthritis.

bilateral salivary glands swelling.

Diagnosis Diagnostic tests include: 1. Schirmers tear function Using two strips of red litmus papers placed at the inner side of the lower eyelid (area of lacrimal glands). A positive finding is lacrimation of 5 mm.
2. 3.

Sialography will give the apple-tree in blossom appearance. Salivary biopsy (either from the lower lip or the tail of the Immunologic and hematologic laboratory studies.

parotid gland.
4.

Treatment 1. Dry foods, smoking and alcohol consumption should be avoided. 2. Treatment is directed to:
a. Supportive care with sialogauges to stimulate salivation and

salivary replacement by means of methylcellulose. b. Supportive care with artificial tears. c. Treatment of the autoimmune connective tissue diseases.

5. Non-inflammatory disorders (Sialadenosis) (metabolic)

Definition A non specific term used to describe a non-inflammatory, non-neoplastic enlargement of a salivary gland usually the parotid gland. Types 1. Metabolic or endocrine sialdenosis:

As in diabetes mellitus. Lack of clinical evidence of local heat, induration, or

tenderness differentiates these disorders from an inflammatory parotitis. 2. Nutritional

Due to Starvation or malnutrition. The swelling is usually bilateral and diffuse. A history of alcoholic-related cirrhosis.

3. Alcoholic cirrhosis: 4. Drug induced:

Drug effects on the salivary glands, predominantly the parotid Include anticholinergics, antidepressants (particularly

glands.

tricyclics), antihypertensives, and antihistaminics.

6. Obstructive disorders
A. Sialolithiasis Definition The formation of calcific masses (stones) within the ductal system of a major or minor salivary gland. Causes of obstruction include
1. 2. 3. 4. 5. 6.

Salivary calculi (Sialolithiasis). Strictures or kinks of the duct wall. Oedema or fibrosis of the papilla. Pressure on the duct due to an adjacent mass. Invasion of the duct by a malignant neoplasm. Mucous retention/extravasation.

Clinical features 1. It occurs in men twice as often as in women.

2. The Submandibular gland is the most common site of

involvement (80%), followed by the parotid (19%).

3. The stones are single, but it may be multiple (more in the

parotid in this case). Etiology The exact nature of stone formation is not known, but may be due to:
1. The calculi are believed to arise from the deposition of ca ++

salt around a nidus of debris within the duct lumen, these debris include bacteria, ductal epith cells, or foreign bodies.

Formation of calculi is also facilitated by several secondary factors: 1. The mucous content of the submandibular gland make its secretions more viscous than the parotid.
2. The duct of the submandibular gland is longer than that of the

parotid gland and runs against gravity in a tortous. 3. The submandibular duct is situated at a lower level than its orifice. Signs and symptoms: 1. Absence of subjective symptoms (discovered accidental). 2. Eating initiates intermittent transient swelling accompanied by moderate discomfort. 3. The involved gland is enlarged and tender.
4. Stasis of the saliva infection, ductal stricture, and ductal

dilatation fibrosis, and gland atrophy. 5. No salivary flow or purulent discharge.

6. If the treatment is not begins: Swelling, redness and tenderness

are present along the course of Whartons duct & pus may exude from the duct orifice.
7. Intraglandular stones seems to cause less severe symptoms than

intraductal ones. Diagnosis: 1. History of swelling at mealtime which subside between meals.
2. Palpation along the course of the duct will frequently confirm

the presence of hard calcific stone.

3. Occlusal view.

4. C.T, MRI, Ultrasound. 5. Sialography.

Treatment Effective treatment of the sialolith depends on the location of the stone and on its effect on gland function.
1. 2. 3.

Stones in the Anterior Duct. Stones in the Posterior Duct. Stones in the Hilum or Gland.

Treatment Modalities Removal of the stone:

Conservative management by: Milking the gland. Shock-wave Lithotripsy (external and intraductal). Surgical removal (Sialolithotomy).

Interventional sialendoscopy
Gland excision (Sialadenectomy).

I. Conservative Management Stone may be removed by spontaneous exfoliation on stimulation of salivation to flush the stone out of the duct: 1.

Indication: Small, mobile stone at or just behinde the duct orifice. Stone causing partial obstruction. Procedures

2.

Hydration. Application of moist warm heat. Gland massage. The use of sialogogues.

Stone may be removed by manipulation: 1. 2. Indication: Small, mobile stone at or just behinde the duct orifice Procedures Open the duct with the aid of lacrimal probes and dilators.

By gentle probing, the stone can be identified, milked forward,

grasped and removed. The gland is then milked to remove any other debris in the more posterior portion of the duct II.Surgical treatment
1.

Extraglandular removal of the stone (sialolithotomy) Intraglandular removal of the gland intraoral approach

intraoral approach.
2.

(sublingual gl) or Extraoral approach (Parotid, submand. gl).

1. Stone removal Surgical removal of submandibular duct sialoliths (sialolithiotomy, sialodochplasty, marsupialization or 2nd duct orifice): Indication
Stones in the anterior duct located in the distal third of the

submandibular duct.
Stones in the posterior duct.

After lingual nerve block local anaesthesia: A suture is passed

into the floor of the mouth around the duct, posterior to the stone, to prevent its dislodgement posteriorly.

A second suture is placed between the submandibular duct Gentle traction of the two sutures will make the tissues at the

papilla and the frenum.

surgical site steady and taut, allowing the mucosa to be cut easily or inserting a lacremal probe into the duct orifice instead of the second suture. stone

An incision is made along the line of the duct and over the The sialolith can be released. The duct lumen is washed by saline through the incision. All the previous sutures are removed & the ductal incision is

not sutured to prevent stricture of the duct. Surgical removal of parotid duct sialoliths (sialolithiotomy)

Sialolithotomy when the stone is at or just behind the duct orifice know as Parotid duct meatotomy.

Meatotomy: An incision made to enlarge a meatus. A semilunar incision running from above downward in front of the caruncle.

the caruncle, mucosal flap are retracted medially, the cheek is retracted laterally, and free access is gained to the more posterior segments of the duct by simply following the duct with blunt dissection.

When the stone becomes accessible, a longitudinal incision is made in the lateral side of the duct and the stone is delivered.

The duct needs not to be sutured, for simply closing the mucosal flap with deep mattress sutures.

2. Gland removal (sialadenectomy): Indication

Very posterior stones. Intra-glandular stones. Irreversible parenchymal damage.

Removal of submandibular salivary gland

A skin incision two finger below the mandible is

performed.

Once the incision goes through the platysma, the

inferior border of the gland is identified & intracapsular dissection is performed.

Mobilizing the overlying fascia and capsule of the

gland superiorly, protect the mandibular branch of the facial nerve.

The posterior & inferior borders of the gland are

mobilized with finger dissection.

The inferior border of the gland is followed

anteriorly to allow the anterior border o f t h e g l a n d t o b e m o b i l i z e d f r o m t h e mylohyoid muscle.

Once the anterior pole is free, the gland can retracted

posteriorly to e x p o s e t h e p o s t e r i o r e d g e o f t h e mylohyoid. The muscle is retracted to visualize the

lingual nerve & Wharton's duct. The nerve connection from the lingual nerve to

the gland is cut, and the duct is dissected from the nerve.

The duct is dissect as far as possible forward into

the floor of the mouth and then ligated and sectioned.

Small part of the duct should be remain because

the secretion from the lingual gland entering the W h a r t o n ' s duct.

Removal of parotid salivary gland

The incision runs from the superior attachment of the pinna

downward, turns anteriorly at the angle of the mandible, and stops at the hyoid bone.
A second incision which may be made posterior to the pinna, joins

the first at the inferior margin of the pinna.

The ear is retracted from the operative field, and the skin flap is

developed on the cheek side of the incision.

After the facial nerve has been identified, the course of

the trunk is followed and the superficial lobe is freed from its
5

attachments.

The duct is ligated and cut. After the superficial lobe of the gland has been freed

and the main branches of the facial nerve have been identified, the deep lobe may be approached.

This lobe wraps around the posterior border of

the mandible, and dissection in this space is facilitated by posterosuperior retraction of the ear.

Care should be taken to protect the external carotid

artery and the posterior facial vein during this operation.

Care must be exercised, while the pinna is retracted, not to

incise the acoustic meatus during separation of the gland.

Most dead space may be closed by careful suturing after removal

of the gland.
A drain may be indicated in the wound, especially if a portion

of the gland is removed and salivary accumulation is expected.

III. Modern treatment of obstructive salivary diseases

1.

Sialolithotripsy: e.g. shock wave (fragmentation). Shock-waves fragmenting salivary stones flushing

out from the salivary duct system

1.

Types External lithotripsy: results were poor specifically in

patients with large calculi.

2.

Interventional

sialendoscopy

with

intraductal

laser

fragmentation and basket extraction of calculi (success rate 80%).

3.

Endoscopically

Intracorporeal

Electrohydraulic

Lithotripsy: consist of electrohydraulic lithotripter + Autolith + probe which can be inserted into the working channel of the sialendoscope. 2. Interventional sialoendoscope:
-

It allows removal the stone while preserving the gland. If < 3mm: Removed by wire basket & mini forceps. If > 3mm: Laser beam sialoendoscope is used. Fragments are removed using wire basket or mini forceps. Postoperative-care: 1-Milking of the gland. 2-Sialogogues. 3-Analgesics & antibiotics.

B. Ductal stenosis & Strictures (Sialoangiectasis) Types:

Type 1: diffuse narrowing of the small ductular branches. Type II: localized stricture (less than 1cm in Type III: diffuse narrowing of the main duct. Type IV: affects the whole ductal,system (main duct & small Type IVa: diffuse reduction in caliber in the whole ductal

length) of the main duct.

branches) system.

Type IVb: diffuse reduction in caliber + strictures Congenital. 2 ry to trauma or surgery. Recurrent infection. Recurrent unilateral swelling and pain at meal time. Recurrent infection. Sialography by stretching duct wall as result of CM

Etiology:

Clinical manifestations:

Diagnosis:

injection. Treatment A. Interventional Sialoendoscopy:

Use Sialo-Balloon (inflated inside the duct). Hollow Bougies in severe stenosis. Milking of the gland. Sialogogues. Analgesic &antibiotics. Edema or fibrosis of the papilla. Pressure the duct due to an adjacent mass. Invasion of the duct by a malignant neoplasm. Mucous retention (Extravasation phenomena).

B. Post-operative care and medications:

A. B. C. D.

7. Functional disorders
A- Xerostomia (Dry Mouth) Definition: it's the decrease in salivary flow. Etiology: a. Organic diseases: Sjogren syndrome. D.M. Hepatitis.

 Radiotherapy. b. Functional disorders:

Dehydration. Fluid loss.

c. Drugs:

Anti-histaminics, Anti-emetic, Anti-depressant. Atropine (Parasympatholytic). Pseudoephidrine (Panadol Cold and Flu). B-Blockers.

Clinical manifestations:

Inflammation of tongue and oral mucosa. Loss of taste sensation. Dysphagia. Rampant caries. Could be temporary No complications.

Diagnosis:

History. CI. Examination. Sialography slow evacuation of contrast medium.

Management: 1. Preventive Therapy

The use of topical fluorides to control dental caries. The use of antifungal therapies to control the increase in oral

infections, particularly mucosal candidiasis. 2. Symptomatic Treatment

Patients should be used water throughout the day; this will

help to moisten the oral cavity, hydrate the mucosa, and clear debris from the mouth.

The use of room humidifiers may decrease discomfort. Patients should be avoiding oral rinses and gels containing Glycerin paints to avoid inflammation.

alcohol, sugar, or strong flavorings that may irritate the dry mucosa.

3. Salivary Stimulation

Sialogogues: a. Chemical stimulant e.g. Lemon juice.

b. Mechanical stimulant e.g. chewing gum. c. Pharmaco-stimulant e.g. Pilocarpine.

B. Si l orrh oea (P tyal i sm ) Definition: it's an increase in salivary flow. Etiology:

salivary secretions e.g. Mentally retarded children. swallowing of saliva e.g., Patients with Parkinsonism or cerebral palsy.

Clinical manifestations:

Drooling of saliva.

Angular cheilosis.

 Diffuse parotid/submandibular salivary gland enlargement. Diagnosis:

History. Clinical examination. Sialogaphy rapid evacuation of contrast medium.

Management:
1. P s y c h o t h e r a p y . 2. Medical treatment:

Anticholinergic (parasympatholytic) drugs e.g. Atropine, Neastiamine. Botulinum toxins prevent acetylecholine secretion at parasympathetic ganglion. B-Blockers. Radiotherapy cause fibrosis for S.G & has a lot of side effects and not safe for children.

3. Surgical management:

Usually done to submandibUlar S.G (responsible Transposithn of the submandibular S.G duct. Sialadenectomy of Sublingual S.G. Procedure:
G.A. Dissection of submandibular S.G duct and pull it

for 70% of secretions).

by suture.
Duct is tunneled beneath mucosa posteriorly to open in

the base of the anterior pillar of the fauces.

 If sublimgual S.G is left may cause Ranula. Sialadanectomy of Sublingual S.G.

8. Tumors
A. Benign tumors 1- Mixed tumor (pleomorphic adenoma) Incidence and location
1. 2. 3.

Most common salivary gland tumors. The majority arise in the parotid (84%). Mixed tumors account for more than 50% all

intra-oral minor salivary gland tumors. Clinical features

1.
2.

In the parotid gland, these neoplasms are slow growing and In the submandibular glands, these neoplasms are well-defined Intraorally, the mixed tumor most often occurs on the palate, Mobile, except when they occur in the hard palate, where they

usually occur in the posterior inferior aspect of the superficial lobe. palpable masses. 3.
4.

followed by the upper lip and buccal mucosa. are adheres firmly to the underlying tissue. Treatment 1.
2.

Complete excision with 1 cm margins of clinically uninvolved For the parotid gland superficial parotidectomy with For the Submandibular gland, complete excision of the gland is For intraoral tumors extracapsular excision is indicated

normal tissue. preservation of the facial nerve.

3.

indicated.
4.

including the overlying mucosa and saucerization of any bony margins of resection. 2- Monomorphic adenoma Benign salivary gland tumors composed predominantly of epithelium with no evidence of mesenchymal tissue. Incidence and location
1.

Rare tumor the parotid and minor salivary glands. A submucosal nodular mass. Freely mobile firm to slightly compressible. Normal color of overlying mucosa.

Clinical features
1. 2. 3.

Treatment Extracapsular surgical excision

5

3-warthin's tumor (cystadenolymphoma, papillary cystaenoma lymphatosum) Incidence and location

1. 2.

6% of epithelial tumors of the salivary glands. Almost in the parotid gland. 3-4% of all minor salivary gland tumors Intraorally, most commonly in the palate and buccal mucosa. Soft to firm. Asymptomatic mass in the parotid. It grows slowly. Arise from salivary gland tissue sequestered in lymph nodes. Surgical excision with safety margins and superficial Because this tumor contains oncocytes, it will take up

3.
4.

Clinical features
1. 2. 3. 4.

Treatment
1.

parotidectomy. 2. technetium and will be visible on technetium scintiscans. 4- Oncocytoma (oxyphilic asenoma)

Incidence and location: most commonly in the parotid gland Clinical features: Painless solid rounded tumors. Treatment: For parotid gland superficial parotidectomy +

and rarely intraorally.

preservation of the facial nerve. 5. Basal cell adenoma

Incidence and location: 70 % in parotid gland. Intraoral in the

upper lip
5

Clinical features: Appear as painless, well circumscribed and Treatment: For parotid gland superficial parotidectomy. 6. Myoepithelioma

smaller than plemorphic.

Incidence and location: Superficial lobe of parotid gland. Clinical features: Firm, Circumscribed, painless mass. Treatment: Excision with safety margin. 7. Sialadenoma papilliferum

Incidence and location: Minor salivary gland in the buccal Clinical features: Exophyltic mass, verrocous like lesion. Treatment: Excision with minimal margin.

mucosa and palate.

8. Sebeceus adenoma

Incidence and location: Parotid gland Clinical features: Painless, movable, well circumscribed mass. Treatment: superficial parotidectomy. 9. Intraductal adenoma

Incidence and location: minor salivary gland & upper lip. Clinical features: Firm, painless, freely movable mass. Treatment: Excision with 0.5 cm margin of surrounding

tissues and overlying mucosa.

B) Malignant tumors 1- Mucoepidermoid carcinoma Incidence and location:

1. 70 % in the parotid. 2. 20 % minor salivary glands.

3. 10 % submandibular gland. Clinical features:

1.

The low-grade tumor in the palate Grow very slowly Not ulcerated until after very long time Appear bluish in color Don't invade the bone Freely movable Firm Circumscribed mass Faster growing Diffuse Ulcerate early Destruct underlying bone Painful Diffuse mass Fixed Facial nerve affection

2.

The low-grade tumor in parotid

3.

The high-grade tumor in the palate

4.

The high-grade tumor in parotid

Treatment

1.

The low-grade tumor in the palate Tumor excision with 1 cm of soft tissues margin. Hemimaxillectomy + postoperative radiotherapy. Bilateral neck dissection. Involve superficial lobe and without facial nerve If it extend to deep lobe or involve facial nerve total The high-grade tumor in the palate

2.

3.

The low-grade tumor in parotid

involvement superficial parotidectomy + nerve preservation.

parotidectomy + nerve resection then nerve grafting.

4.

The high-grade tumor in parotid

Total parotidectomy + nerve resection. Ispilateral neck dissection + radiotherapy postoperative.

2- Adenocystic carcinoma Incidence and location

1. 2.

Most common in the palate Most common malignant tumor of Submandibular S.G and

parotid G. Clinical features: 1. In major S.G: Parotid G.: Single mass, Occur deep in superficial lobe, Affect facial nerve.

 2.

Sumandibular S.G: Single mass, Affect In minor S.G:

facial nerve and lingual nerve. Palate: Ulcerated mass, Decrease in sensation of the palate, Fixed to the tongue. Tongue: Asymptomatic for long period, Deep pain in the tongue. Treatment Because of the ability of this lesion to spread along the nerve sheaths, radical surgical excision of the lesion is the treatment.
1.

For palate: Hemi-maxillectomy with 3 cm safely margin Complete extirpation of pterygomaxillary space till Extirpation of greater palatine nervous bundle to skull skull base base

2.For Parotid G:

Total parotidectomy + nerve preservation if facial If it involves facial nerve total parotidectomy +

nerve not involved

nerve resection then nerve grafting. 3. For Sumandibular S.G and Tongue:

Radical excision & post surgical radiotherapy and chemotherapy. 3- Polymorphous low grade Adencarcinoma

It occurs almost exclusively in minor salivary glands A painless mass. Treatment: Wide surgical excision.

4. Acini cell carcinoma

It occur mainly in the parotid G Appear as small, freely movable mass, slowly growing Treatment: superficial parotidectomy without ispilateral

neck dissection. 5. Carcinoma explemorphic adenoma

It occur mainly in the parotid G Occur in long standing pleomorphic adenoma Treatment: Radical excision & post surgical

until reach large size.

radiotherapy.

Complications can occur after parotidectomy:

1. 2.

Permanent partial or total facial nerve paralysis. A salivary fistula or sialocele.

3.

Freys syndrome (Sweating Gustatory Syndrome): This syndrome is characterized by flushing or sweating of the Cause: injury of auriculotemporal nerve. Aberrant regeneration theory: auriculotemporal facial skin during meals.

nerve carries sympathetic fibers to the sweat glands of the facial side and parasympathetic fibers to the parotid gland. When the nerve is injured, these nerve fiber(s) regenerate, parasympathetic nerve fibers become misdirected and grow along sympathetic pathways.

ttt: Intracutaneous injection of botulinum toxin.

Recent advances in the management of salivary gland disease

1. Facial nerve preservation

Modification of the retrograde dissection of the facial nerve in Identification of the buccal branch then a retrograde dissection

which:

to the main trunk of the facial nerve performed 4 cm anterior to the tragus along the alatragal line to preserve it. Dissection then follows the conventional antegrade technique.

The use of extracapsular lumpectomy as a conservative

surgical approach to remove benign parotid tumours. 2. Salivary stones and obstructive sialadenitis

Sialoendoscope. Sialodochoplasty with microsurgical repair by an extraoral

approach is a modern technique for removing stones from the hilum that preserved the gland itself. 3. Surgical incisions for parotidectomy

The incisions for access to the parotid gland usually have Various modifications to these incisions have been used to Face-lift incision with an endaural, and a cervical

cervical, postauricular and preauricular components. obtain a better aesthetic outcome which are:

component within the hairline + sternomastoid platysmal flaps, and fat grafts.

Face-lift incision with a superficial musculoaponeurotic

system advancement flap.

4. Complications of salivary gland surgery

One of most complication is Frey syndrome (gustatory To avoid this complication various interpositional grafts have The sternomastoid muscle flap. Temporalis myofascial flaps. Autologous adipose tissue. The superficial muscular aponeurotic system (SMAS)

sweating).

been used including: layer.

Recently, we use the allogenic acellular dermal matrix (ADM)

for the prevention of Frey syndrome and also as a filler to avoid poor aesthetic results secondary to a depression in the residual defect. As a general rules, ask the patient to clench his teeth to stretch the masseter muscle for parotid gland or ask the patient to raise the tongue in his palate to stretch the mylohyoid muscle for submandibular gland so if the lump:
1.

Retain mobility and is more prominent when the underlying Is more prominent but less mobile when the underlying

muscle is contracted, the lump is superficial to muscle. 2. muscle is contracted, the lump is attached to fascia or superficial surface of muscle.
3.

Is less mobile and less prominent when the underlying Is less mobile and less prominent when the underlying

muscle is contracted, the lump is within muscle.

4.

muscle is contracted, the lump is deep to muscle.