1. Salivary glands in Surgery Presented by: Dr. Rafiq M. Salhab. Alahli Hospital, Hebron. 10/10/2011. بسم الله الرحمن الرحيم Al-Quds University Faculty of Medicine

2. Salivary glands Introduction: 1. 1. Major salivary glands:   Two submandibular glands.   Two parotid glands.   Two sublingual glands. 2. 2. Minor salivary glands. > 400 minor salivary glands.

3. Minor salivary glands: Anatomy:   Oral cavity contains ~ 450 minor salivary glands, just under mucosa.   Distributed under the mucosa of the lips, cheeks, palate, floor of the mouth and retromolar area.   Present also in oropharynx, larynx, trachea and the sinuses.   Histological: they are similar to the mucous secreting major glands.   10% of the total salivary volume.

4. Common disorders of minor salivary glands: 1. 1. Cysts. 2. 2. Tumors.   Cysts:   An extravasation is very common.   The cysts arise as a result of trauma to the overlying mucosa.   They usually affect the lower lip.   Clinically: painless swelling, soft and often translucent.   Treatment:   Spontaneous resolution.   Surgical excision.   Recurrence is rare.

5. Tumors of minor salivary glands:   Histologically are identical to those of major glands.   90% of minor salivary glands tumors are malignant.   They occur anywhere in the aerodigestive tract.   Common sites: Upper lip, palate and retromolar region. Less common in nasal and pharyngeal cavities.   These tumors occur in the submucosal seromucous glands.   Very rarely a mucoepidermoid carcinoma can present as an intraosseous tumor of the mandible.

6. Benign tumors:   Painless, firm, slow growing mass, ulcerations are rare.   Upper lip tumors: excision and primary closure.   Palate: < 1cm = excisional biopsy. > 1cm = incisional biopsy for diagnosis. Malignant tumors:   More firm consistency.   Necrosis and late ulcerations are common.   Discoloration of overlying mucosa (pink to blue or black).   Management: -wide excision. -palate tumors may need total maxillectomy (prosthesis, graft).

7. Necrotizing sialometaplasia:   Self-limiting benign disease.   Occurs at the junction of the hard and soft palate.   Etiology: salivary gland tissue infarction.   Clinically are similar to malignant tumors (biopsy is indicated).   Treatment: reassurance and symptomatic relief. (all lesions resolve within 6-10 weeks)

8. Major salivary glands: - Sublingual glands Anatomy: Anatomy:   Two small salivary glands lying in the anterior part of the floor of the mouth.   Numerous excretory ducts that open directly into the oral cavity, or indirectly into the submandibular duct. Common disorders of the submandibular glands: Cysts: large ones may need surgery. Ranula: frog’s belly.   Numerous extravasation cyst arising from the sublingual gland.   Translucent, painless, soft swelling.   Treatment: Spontaneous resolution. Incision and drainage, usually result in recurrence. Excision of the cyst and the sublingual gland affected.

9. Pulging Ranula: Pulging Ranula:   Can arise from both sublingual or submandibular salivary glands.   The mucus collects around the gland and penetrates the mylohyoid diaphragm to enter the neck.   Dumb-bell-shape swelling that is soft, fluctuant and painless in the submental or submandibular region.   Diagnosis: US, MRI.   Treatment: Cervical approach, removing the cyst, the submandibular and the sublingual gland. Smaller pulging ranulae can be treated by transoral approach.

10. Tumors of the sublingual gland:   Tumors involving the sublingual gland are very rare.   They present as a hard or firm painless swelling in the floor of the mouth.   90% are malignant.   Frequently require wide excision and neck dissection.

11. - Submandibular gland: Anatomy:   Paired salivary glands that lie bellow the mandible on either side.   Divided into two lobes: Large superficial lobe. Smaller deep lobe.   Enclosed in the capsule of the deep cervical fascia.   Important anatomical relationship: Anterior facial vein over the surface of the gland. Facial artery. Lingual nerve. Hypoglossal nerve superiorly. Marginal mandibular branch of facial nerve.   Drained by a single submandibular duct (Wharton) which open into the anterior floor of the mouth at the sublingual papilla.   Several lymph nodes immediately adjacent; sometimes within the superficial part of the gland.

12. Developmental disorders of submandibular gland: 1. 1. Congenital absence: extremely rare. 2. 2. Duct Artesia: submandibular swelling within 2-3 days of life and retention cyst within the gland. 3. 3. Ectopic/aberrant salivary gland tissue: Stafne bone cyst: Most common Asymptomatic well-demarcated radiolucency of the mandibular angle. Etiology: invagination into the bone by an ectopic lobe of submandibular gland. No treatment is required.

13. Inflammatory disorders: Acute submandibular sialoadenitis: 1. 1. Viral. 2. 2. Bacterial. Viral submandibular sialoadenitis:   Paramyxovirus (mumps): usually produces parotitis. (Submandibular glands are occasionally involved).   Other viruses are rare.   Clinically: pain, swelling and tenderness of the gland.   Treatment: symptomatic. Bacterial submandibular sialoadenitis:   More common than viral sialoadenitis in the submandibular gland.   Usually occurs secondary to obstruction.   The submandibular gland has a poor capacity for recovery.   despite control of acute symptoms with antibiotics, chronicity is very common and requires formal excision.

14. Chronic submandibular sialoadenitis: ( caused by obstruction or trauma). The most common cause of obstruction is stone formation (sialolithiasis) within the gland or duct system. 80% of all salivary stones occur in the submandibular gland. 80% of submandibular stones are radiopaque and can be identified on plain radiography. Clinical symptoms: 1. 1. Acute painful swelling in the region of the submandibular gland. 2. 2. Pain is precipitated by eating. 3. 3. The swelling occurs rapidly and often resolves spontaneously (1-2 hours after the meal is completed). When the obstruction is partial the symptoms are more infrequent producing minimal discomfort and swelling not related to meal-time. 4. 4. Enlarged and firm gland on bimanual examination. 5. 5. Pus may be visible draining from the sublingual papilla.

15. Management: 1. 1. If the stone is in the floor of the mouth it can be removed from oral cavity (longitudinal incision kept open). 2. 2. When the stone is at the hilum of the gland approach is from outside the mouth and the stone and the gland are removed. Complications of submandibular gland excision: Hematoma. wound infection. Marginal mandibular nerve injury. Lingual nerve injury. Hypoglossal nerve injury. Transection of nerve to the mylohyoid muscle producing submental skin anesthesia.

16. Tumors of the submandibular gland:   They are uncommon.   Present usually as slow-growing painless swellings within the submandibular triangle (benign or malignant).   50% are benign.   Clinically cannot be differentiated from submandibular lymphadenopathy.   Tumors sometimes are painful (benign or malignant). Clinical features of malignant tumors: Facial nerve weakness. Rapid enlargement of swelling. Induration and/or ulceration or discoloration of overlying skin. Cervical lymph node enlargement.

17. Investigation:   US: size, cystic or solid, adjacent structures, LN envolvement.   CT scan and MRI: Are the most helpful. Circumscribed and benign border. Diffuse, invasive and malignant. Can determine resectability of the tumor.   Open surgical biopsy: is contraindicated → seeding the tumor.   True-cut biopsy: contraindicated.   Fine needle aspiration (FNA): the use is controversial, it is safe when the needle gauge does not exceed 18G. Management: Excision of the tumor with a cuff of normal tissue.

18. - The Parotid gland: Anatomy:   Lies in a recess bounded by the Ramus of the mandible, base of the skull and mastoid process.   Lies on the carotid sheath, enclosed in a sheath of deep cervical fascia.   Upper pole extends just bellow the zygoma and the lower pole into the neck.   Several important structures run through the parotid gland. Branches of facial nerve. Terminal branches of external carotid artery (MA,STA). Retromandibular vein. Intraparotid lymph nodes.   The gland is divided into superficial and deep lobes by the facial nerve. ( 80% of the gland is superficial to the nerve and 20% lies deep to it).   Accessory lobe in < 50% of population.

19. Developmental disorders: Agenesis, duct atresia and congenital fistula are extremely rare. Inflammatory disorders: 1. 1. Viral infections. 2. 2. Bacterial infections. Viral parotitis: (Mumps)   Mumps is the most common cause of acute painful parotid swelling.   Predominantly affects children.   Air-borne droplets of infected saliva.   Prodromal period of 1-2 days (fever, nausea, headache) followed by pain and swelling of one or both glands.   Pain can be very severe increasing by eating or drinking.   Symptoms resolve within 5-10 days.   Single episode of infection confers lifelong immunity. Diagnosis: history, clinical examination, recent contact with an infected patient with a painful parotid swelling.

20. Atypical viral parotitis: (unilateral or submandibular involvement). diagnosis is made by rising antibody titer to the mumps S and V antigen. Treatment: symptomatic. Analgesia. Adequate oral fluid intake. Complications: are rare and more common in adults. Orchitis. Oophoritis. Pancreatitis. Sensory neural deafness. Meningoencephalitis. Other viral parotitis: Coxakie A and B. Parainfluenza 1 and 3. Echo. Lymphocytic choriomeningitis.

21. Bacterial parotitis: 1. 1. Acute bacterial sialoadenitis. 2. 2. Recurrent parotitis of childhood. 3. 3. Obstructive parotitis. Acute bacterial sialoadenitis:   Historically described in elderly dehydrated patients following major surgery with bad oral hygiene.   Ascending infection via the parotid duct.   Now is more commonly seen in fit adult with no obvious precipitating factors. Clinically: Tender, painful parotid swelling (diffuse, lower pole) which arise over several hours. Fever. Generalized malaise. Cervical lymphadenopathy. Intraoral examination may reveal pus exuding from the parotid gland papilla.

22. Organism: Staphylococcus aureus. Streptococcus viridans. Sialography is absolutely contraindicated during acute infection. Management:   General support.   Culture.   Broad spectrum antibiotics and penicillinase–resistant agent (2-3 days).   If there is no improvement, change antibiotic according to culture.   If the gland becomes fluctuant US is indicated to identify abscess: Aspiration with a large-bore needle. Surgical drainage. Chronic bacterial sialoadenitis is rare in the parotid gland.

23. Recurrent parotitis of childhood:   Recurrent attacks of one or both sides. Swelling. Pain. Fever. Malaise.   Symptoms increase by chewing and eating.   Duration for 3-7 days.   Quiescent periods, weeks-several months.   Age: 3-6 years (4 months cases). Diagnosis: Sialography. (snow storm) Management: Short courses of antibiotics. Prophylactic low-dose antibiotics for several months or even years. Parotidectomy is rarely indicated with onset of disease early in childhood.

24. HIV-associated sialoadenitis: 1. 1. Chronic parotitis in children :   Chronic parotitis in children is pathognomonic of HIV infection   HIV-associated sialoadenitis is very similar to Sjögren syndrome in adulthood (with negative autoantibody screen). 2. 2. Multiple parotid cysts:   Gross swelling and facial disfiguring (painless).   CT,MRI: Swiss cheese appearance.   Surgery may be indicated to improve the appearance.

25. Obstructive parotitis: Less common than obstructive submandibular sialoadenitis caused by: 1. 1. Trauma to the papilla. 2. 2. Stone formation. 3. 3. Tumors. Papillary obstruction:   Trauma to the parotid papilla by upper denture or fractured upper molar tooth.   Inflammation and oedema produced obstruct salivary flow particularly at meal-time with rapid onset of pain and swelling.   If left untreated → progressive scarring → fibrosis →permanent stenosis around the papilla. Treatment: Elimination of causes. Papillotomy.

26. Stone formation:   Less common than the submandibular gland.   Stone are usually translucent.   20% of all salivary glands stones.   Located at the confluence of collecting ducts or near the papilla.   Parotid gland US or Sialography is usually required to identify the stone. Treatment: surgical removal of the stone. Tumors of the parotid gland:   Parotid gland is the most common site of salivary tumors.   Most tumors arise in the superficial lobe (rarely in the deep).   80-90% are benign (most common Pleomorphic adenoma). Clinically: slow-growing painless swelling: Bellow the ear, in front of the ear, in the upper aspect of the neck, within the cheek (accessory lobe), parapharyngeal space (deep lobe which causes difficulty in swallowing and snoring).

27. Classification of salivary gland tumors: 1. 1. Benign: most common Pleomorphic adenoma (mixed tumor). 2. 2. Malignant:   Low-grade malignant tumors (Acinic cell carcinoma), indistinguishable on clinical examination from benign tumors.   High-grade malignant tumors: Rapidly growing. Often painful. Discrete mass that can infiltrate the overlying skin. Diffuse hard swelling of the gland. Patients present with advanced disease and cervical lymph node metastases. Facial nerve weakness is a sign of malignancy when present. Investigations: CT and MRI are the most useful. FNA may help in preoperative diagnosis, but open surgical diagnosis is contraindicated.

28. Management:   All space-occupying lesions of the superficial lobe should be managed by superficial parotidectomy.   No place for enucleation of the swelling, even a benign lesion is suspected.   Radical parotidectomy is performed when there is clear histological evidence of a high grade malignant tumors with extensive facial nerve infiltration (squamous cell carcinoma). Complications of parotid gland surgery: 1- Hematoma. 2- Infection. 3- Temporary facial nerve weakness. 4- Permanent facial nerve weakness. 5- Sialocele. 6- Salivary–cutaneous fistula. 7- Facial numbness. 8- Permanent numbness of the ear lobe. 9- Frey syndrome.

29. Frey syndrome: gustatory sweating:   Damage of the innervation of the salivary gland during dissection.   Inappropriate regeneration of parasympathetic autonomic fibers which thus stimulates the sweat glands of the overlying skin. Clinically: sweating and erythema over the region of the parotid (surgical bed) as a consequence of autonomic stimulation of the salivation by the smell or taste of food. Diagnostic test: Starch iodine test. Management: A. A. Prevention. B. B. Management of established syndrome. 1. 1. Antiperspirants (aluminum chloride). 2. 2. Denervation by tympanic neurectomy. 3. 3. Injection of botulinum toxin into the affected skin (most modern).

30. Granulomatous sialoadenitis: Mycobacterial infection. Cat-scratch disease. Toxoplasmosis. Sarcoidosis. Syphilis. Deep mycosis. Allergic sialoadenitis. Radiation sialoadenitis. Tumor-like lesions: Sialoadenosis (sialosis). Adenomatoid hyperplasia.

31. Thanks for listening Dr. Rafiq

32. FrequencyTypeLocationType 80 – 90 % 10 – 20 % BenignMalignantParotidMajor 50 % BenignMalignantSubmandibular 5 % 95 % BenignMalignantSublingual 10 % 90 % BenignMalignant Upper aerodigestive tract Minor Table 1.1: Salivary gland tumors: frequency & distribution

33. Common examples SubgroupType Pleomorphic adenoma Warthin’s tumor (adenolymphoma) PleomorphicMonomorphic 1. Benign (Adenoma) (Adenoma) Acinic cell Adenoid cystic MucoepidermoidAdenocarcinoma Squamous cell MucoepidermoidLow-gradeHigh-grade 2. Malignant (Carcinoma) Table 1.2: Classification of salivary gland tumors (simplified)

34. HemangiomasLymphangiomas 3. Non-epithelial tumors tumors Non-Hodgkin’s Lymphoma in Sjögren syndrome PrimarySecondary 4. Lymphomas Tumors of head and neck Skin and bronchus LocalDistant 5. Secondary tumors 6. Unclassified tumors Adenomatoid hyperplasia Benign lymphoepithelial Salivary gland cysts SolidCystic 7. Tumor-like lesions