3. Anatomy
3 major salivary glands:
◦ The parotid glands
◦ The submandibular glands
◦ The sublingual glands
Many minor salivary glands in mucosa of
cheeks, lips, palate.
4. Parotid gland
Largest salivary gland
Lies b/w sternomastoid and mandible
below the EAM
Coverings :
◦ True capsule
◦ False capsule – a layer from the deep cervical
fascia
5. Lobes of parotid gland
Parotid divided into superficial and deep
lobes by the facial nerve
Fasciovenous plane of Patey
6.
7.
8. Structures within the parotid gland
1. External carotid artery :
2. Retromandibular vein
3.Facial nerve.
9. Structures within the parotid gland
3. The facial nerve
◦ Enters upper part of posteromedial border
◦ Passes forward and downward and divides
into
Temporal br.
Temporofacial Zygomatic br.
Main trunk
Buccal branches
Cervicofacial Marginal mandibular br.
Cervial br.
11. Parotid duct
Stensen’s duct
5cm in length
Comes out through anterior surface of
glands.
Peirces buccinator and opens in buccal
mucosa opposite crown of second upper
molar tooth.
12. Submandibular gland
Composed of superficial part and deep
part
Divided by mylohyoid muscle
Superficial part lies in the submandibular
triangle b/w 2 bellies of digastric muscle
Deep part lies abv & deep to mylohyoid in
the floor of mouth
13. Submandibular duct (Wharton’s
duct)
About 5 cm long
Runs fwd from the deep part of the gland
to enter floor of the mouth
Opens on a papilla beside the frenulum of
the tongue
16. Neoplasms of the salivary gland
Salivary gland neoplasms forms 1% of all
head and neck tumours.
75% occur in the parotid glands.
◦ In parotid glands, 80% of tumors are benign.
◦ Of these 80% are Pleomorphic adenomas.
15% of salivary tumors occur in
submandibular glands.
◦ Of these 50% are benign and 50% and malignant.
In carcinomas mucoepidermoid ca> adenoid
cystic ca > adenocarcinoma
17. 10% of salivary tumors occur in sublingual
and minor salivary glands
◦ 60-70% of these are malignant
18. Classification
A. Epithilial tumors
B. Connective tissue tumors
C. Metastatic tumors
22. Pleomorphic adenoma
It is a ‘Mixed tumor’
Commonest tumor of salivary glands.
Histologically it is charcterized by complex
intermingling of epithelial component and
mesenchymal areas.
Sites : 90% Parotids
7% Submandibular gland
3% rest
Origin:According to the multicellar theory,these
tumours orginate from intercalated duct cells and
myoepithelial cells of the salivary glands.
23. Pathology
Macro : rubbery, on cut section, mucoid
appearance with zones of cartilage.
Micro : pleomorphic stroma with
pseudocartilage, lymphoid, myxoid and
fibrous elements besides epithelial cells.
24. Clinical features
Age : any age but common around 40 yrs
Sex : slightly more incidence in females.
Painless swelling since years.
Slow growth.
Site : usually below the lobule of ear.
Variable consistency : firm and rubbery
25.
26. Malignant transformation
Malignant transformation may occur in 3%
to 5%
Signs of malignant transformation :
◦ Long duration (10-20yrs)
◦ Becomes painful
◦ Starts growing rapidly
◦ Becomes stony hard
◦ Facial nerve involvement
◦ L. node involvement.
◦ Jaw movement restriction.
27. Treatment
The tumor is radioresistant.
Excision is the treatment of choice.
For diagnosis FNAC can be done but
incisional biopsy is contraindicated.
Superficial parotidectomy is the treatment
of choice.
Submandibular gland : submandibular
gland excision.
28. ADENOLYMPHOMA (Warthin’s
tumor):
Adenolymphoma was first reported by
Albrecht and Arzt in the year 1910.
It is primarily occuring in the parotid
Represents 5-15% of parotid tumors.
Occurs only in parotid.
Almost always in lower portion of parotid
gland.
29. Pathology
Gross : soft and frequently cystic
Micro : cores of papillary processes with
abundant lymphoid tissue.
30. Clinical features
Age : middle and old age
Sex : much more common in males
Painless slow growing tumor over angle of
jaw
May be bilateral
Surface is smooth
31. Management
Treatment : superficial parotidectomy with
care taken to preserive the facial nerve.
32. ONCOCYTOMA(OXYPHILIC
ADENOMA):
>Primarily occur in parotid and are composed of
clusters of large eosinophilic granular
cells(oncocytes).
>It was first reported by DUPLAY in 1875 and
according to the multicellular theory of salivary
gland neoplasms,oncocytomas orginate from the
striated duct cells.
33. Clinical features:
age:they usually occur among older
individuals,in their 8th decade of life.
SEX:Female predilection
SITE:Superficial lobe of the parotid is the most
favoured location.
Clinically the tumor often produces slow
enlarging,painless,uninodular or sometimes
multinodular, movable swealling anterior to the
ear or over the ramus of the mandible.
34. HISTOPATHOLOGY:
The tumors are cellular,containing round eosinophilic
cells with a granular cytoplasm.
The nuclei are small and have indentations.
The granular appearance of these cells is the result of
the number of mitochondria present in the cytoplasm.
36. MONOMORPHIC ADENOMA:
It is characterized by proliferation of a
single epithelial cell type that has a
distinctive architectural patter.
It does not exhibit the wide cellular
diversities,which are normally
encountered in pleomorphic adenomas.
Basal cell adenoma is the most common
type.
37. CLINICAL FEATURES:
Basal cell adenomas:
Age; commonly in 6th decade of life
Sex:female
Site:commonly involves parotid(70%) and
20% lession are seen in oral cavity and
intraoral lession commonly arises from
the upper lip and buccal mucosa.
It is slow
enlarging,firm,encapsulated,movabile
lesions and usually measure less than 3cm
.
38. Canalicular adenoma:
Age:in 7th decade of life
Sex:female
Site:Minor salivary glands of the upper lip
are the most common site.
Major gland rare.
Clinically appear as small,painless,movable
encapsulated lesions being covered by a
smooth intact epithelium.
39. HISTOPATHOLOGY:
Tumors contain epithelial parenchyma,which is
sharply denacreted from the scant stroma by a
thick prominet basement appearance.
The epithelial cells have a palisading appearnce at
the periphery of the tumour parenchyma.
42. MUCOEPIDERMOID TUMOR:
It is an unusual type of malignant salivary gland neoplasm with
varying degree of aggressiveness.According to the multicellular
theory ,the mucoepidermiod tumors arises from the excretory
duct cells of the salivary gland.
Tumor are graded into low,intermediate and high grade tumor
depending upon their cells type.
It is made of two types of cells they are
-Mucous cells
-Epidermoid cells
Low grade tumor have a higher proportion of mucous cells
then epidermoid cells.
High grade tumor have high epidermoid cells.
Low grade tumors are smal,encapsulated,non-aggressive.
High grade tumors are infiltrative,non-capsulated.larger
mases,solid,greyish white in appearance.
43. HISTOLOGICAL:
>Low grade tumors contain sheets of
mucoid cells separated by bands of
epidermoid cells.Mucouc cells are clear
and plump with small nuclei.Epidermoid
components resemble squamous cell
carcinoma.
>High grade mucoepidermoid carcinoma
are composed nearly entirely of nests of
malignant epidermoid cells.Few mucous
cells or none at all present.
44. CLINICAL FEATURES:
Age:30 to 40 year
Sex:Female predilection
Site:The tumor frequently involve the
parotid and minor salivary glands of the
palate,lips,buccal mucosa,tongue, and
retromolar areas etc….
46. Acinic cell tumor
Almost all occur in parotid gland
Composed of cells resembling acini
Women > Men
Rare and slow growing
Tend to be soft and occasionally cystic
47. HISTHOPATHOLOGY:
Tumor consists of either serous or mucous acinar cells of
the salivary gland.
Malignant cells are larger round or polyhedral in shape
and have granular basophilic cytoplasm and dark
eccentrically placed nuclei.
Cells are often arranged in acinus-like cluster and they
often resemble the serious acinar cells of the salivary
gland.
Cell cytoplasm may be vacuolated or sometimes entirely
clear
Tumor cells may abe arranged in sheets or solid or cystic
or even papillary cystic patters wuthin a lymphoid stroma.
48. TREATMENT:
By wide local excision or superficial
parotidectomy.
49. Adenoid Cystic Carcinoma
Consists of myoepithelial and duct
epithelial cells
Slow growing but more invasive than the
above described malignant tumors
Tumor is always more extensive than the
physical or radiological appearance
Minor glands > submandibular > parotid
51. TREATMENT:
Surgical excision of the tumor along with
the part of the neural tissue involved is
important.
52. Adenocarcinomas, Epidermoid ca &
Undifferentiated Ca
Resemble various glandular elements seen
in salivary glands
Divided according to predominant cell
type
Demonstrate fixation to adjacent bone,
pain, anesthesia of skin and paralysis of
muscles
53. In case of parotid gland, facial nerve
irritability occurs first, later gives rise to
facial paralysis
Limitation of jaw movements
54. CARCINOMA EX-
PLEOMORPHIC ADENOMA:
This refers to an epithelial caercinoma arising from
pleomorphic adenoma.
This tumor consist of malignant epithelial component
only with no mesenchymal element.
It is rare.
55. CLINICAL FEATURE:
Sudden rapid increase in size of a slow-
growing or stable mass.Facial nerve
involvement is another important feature.
The gross tumor appears firm ,non-
encapsulated ,nodular with areas o0f
central necrosis and heamorrhage.
57. SQUAMOUS CELL CARCINAMO:
Primary squamous cell carcinoma is rae in
salivary glands.
High grade mucoepidermoid carcinoma
should be ruled out which may appaear
similar to squamous cell carcinoma.
Also SCC of skin or upper respiratiry
tract with metastasis to salivary glads
should be ruled out
It has a tendency for local and reginol
spread.
61. Frey’s syndrome
Also called as auriculo-temporal syndrome
Occurs due to damage to the autonomic
innervation of the salivary gland
Inappropriate regeneration of
parasympathetic fibers
Stimulation of sweat glands of overlying skin
with stimulus of salivation
62. Causes :
◦ Surgery of the parotid gland
◦ Injury to parotid gland
Clinical features : sweating and erythema
at the site of parotid surgery by smell or
taste of food.
63. Investigation :
◦ Starch iodine test :
◦ After painting the area with iodine Starch
applied over the area becomes blue on
gustatory stimulus.
64. Prevention
Sternomastoid muscle flap
Temporalis fascial flap
Artificial membranes
Form a barrier between skin and parotid
bed to minimise inappropriate
regeneration of autonomic nerve fibres.
65. Treatment
Initially conservative management
Most recover in 6 months
Anti-perspirants
Denervation by tympanic neurectomy
Injection of botulinum toxin into the
afected skin.
66. Parotidectomy
Types :
1. Superficial parotidectomy : superficial to
facial nerve
2. Total conservative parotidectomy : for
benign diseases involving deep lobe. Facial
nerve is preserved.
3. Radical parotidectomy :
◦ For carcinomas
◦ Facial nerve, fat, facia, muscles and lymph nodes
are removed.
◦ Later reconstruction using hypoglossal or
greater auricular nerve.
69. Identificaton of facial nerve
Conley’s pointer : inferior portion of
cartilagnous canal. Facial nerve is 1cm
deep and inferior to its tip.
Upper border of posterior belly of the
digastric muscle. Fascial nerve
immediately superior to this.
By nerve stimulator
70. How To Save The Facial Nerve During
Parotid Salivary Gland Tumor Surgery.flv
72. Facial nerve injury(Lower motor
neuron lesion)
Causes
◦ Trauma
◦ Parotid surgery
◦ Compression of facial nerve(Bell’s nerve)
73. Clinical features
Inability to close the eye lid
Difficulty in blowing and clenching
Drooping of the angle of mouth
Obliteration of naso-labial fold
74. Treatment
Usually temporary, recovers in 6 months
Nerve grafting
Suspension of angle of mouth to
zygomatic bone
Lateral tarsorrhaphy
75. Submandibular gland excision
Indications :
◦ Chronic sialoadenitis
◦ Stone in submandbular gland
◦ Submandibular gland tumors
76. Incision
Placed 2-4 cm below th mandie, parallel
to it
Preserve :
◦ Marginal mandibular nerve
◦ Lingual nerve
◦ Hypoglossal nerve