Seminar 14 15 Salivary Gland Diseases / Orthodontic Courses by Indian Dental Academy

GITAM DENTAL COLLEGE & HOSPITAL
DEPARTMENT OF
Oral & Maxillofacial Surgery

SEMINAR ON
Salivary gland diseases
Presented By:
Dr. Satyajit Sahu
III MDS
Dept. Of Oral Ma!ill"fa#ial Surgery
Salivary glands Diseases and Management
1
Intr"du#ti"n
The salivary glands, major and minor, comprise a complex anatomic and
physiologic organ system producing enzyme, lubrication, mixing agent and immune
factors The salivary glands respond to physical !food and drin"# and emotional
!flight, exhilaration and exhaustion# stimuli They may fall prey to a host of
pathologic conditions, including infection, calculus, immune disorders, hypertrophy
and atrophy, systemic diseases and neoplasms, both benign and malignant
The diseases of salivary glands may be divided into
1 Developmental anomalies
$ %nfections acute
chronic
systemic
& 'eoplasms benign
malignant
( )uto*immune
+ Miscellaneous necrotising sialometaplasia
cystic fibrosis
mucocele and ranula
Devel"p$ental an"$alies
Aberrant salivary gland
)n aberrant !ectopic# salivary gland tissue that develops at a site ,here it is
not normally found This condition is reported as an single anomaly or in combination
,ith other facial anomalies They are most fre-uently reported in the cervical
region near the parotid gland or the body of the mandible The latter is found
posterior to the 1
st
molar and often has a communication ,ith a major salivary gland
$
Most aberrant salivary glands in the nec" occur in the upper portion in the area of
the branchial cleft and bronchial cleft cysts
Aplasia and hypoplasia
Total aplasia of the major salivary glands, though rare, may occur in
combination ,ith other congenital anomalies li"e cleft palate The major symptom is
severe xerostomia .ypoplasia of parotid glands has been reported in patients ,ith
Mel"erson*/osenthal syndrome, ,hich presents as a classical triad of orofacial
granulomas, facial paralysis and fissure tongue
Accessory glands
This is a common condition, found in more than half the people %t is usually
found superior and anterior to the normal Stensson0s duct orifice
Diverticuli
These are small pouches or outpoc"etings of the ductal system of one of the
major salivary glands, and these lead to repeated episodes of acute parotitis
Infe#ti"ns "f the salivary glands
Sialadenitis, infection of salivary gland tissue is a relatively common tissue
%t may be classified as
!%# 1acterial and viral
a# Mumps !viral parotitis#
b# 1acterial parotitis !sialadenitis# i )cute
ii chronic
c# /ecurrent parotitis of childhood
!%%# 2bstructive sialadenitis
a# Sialolithiasis
b# Mucous plugs
c# Stricture stenosis
&
d# 3oreign body
!%%%# Systemic granulomatous diseases
a# Tuberculosis
b# )ctinomycosis
c# 3ungal infection
d# 4veoparotid fever
Acute bacterial parotitis
)cute bacterial parotitis is a disease of the elderly, malnourished,
dehydrated, post*operative and chronically ill patient Dehydration secondary to
acute illness or debilitation result in diminished salivary flo, and retrograde
infection of Stensson0s duct )ntisialogogues, diuretics, antihistamines and
tran-uillisers also can be the causes 5linically, the condition is characterised by
the sudden onset of firm, erythematous s,elling of parotid region and ex-uisite
pain and tenderness 1ody temperature rises and purulent discharge may emanate
from Stensson0s duct %f untreated, it leads to a mar"edly toxic and life*
threatening situation
The treatment of bacterial parotitis includes hydration, antimicrobial
therapy !semisynthetic penicillins are found to be ade-uate#, and drainage if
necessary Drainage is accomplished by the surgical exposure of the gland and
penetration of capsule by blunt probing using a small 6elly clamp
Chronic bacterial parotitis
This may be secondary to an episode of acute parotitis, and is characterised
by unilateral or bilateral s,elling of the parotid and by a course of intermittent
exacerbations and remissions 7arotidectomy is considered to be the definitive
therapy
(
Viral parotitis (mumps)
Mumps is an acute communicable disease, occurring in epidemics and
transmitted by infected salivary secretions and urine %t usually occurs in a child or
in an adult ,ho has previously escaped earlier infection Mumps is characterised by
a rapid, painful s,elling of one 8 both parotids 1+ 19 days after initial exposure
7rodromal phase of 1 $ days of fever, headache etc precedes the s,elling
5omplications include pancreatitis, orchitis and meningitis !due to viremia# Mumps
resolves spontaneously in + 1: days Symptomatic treatment for fever and pain are
necessary
Submandibular sialadenitis
This is less common than parotid infection, and is mostly due to stones and
strictures The clinical importance is that it may be confused ,ith submandibular
space infections of odontogenic origin
Sialolithiasis
Sialoliths are calcified and organic matter that develop in the parenchyma or
ducts of the major or minor salivary glands 1iochemically, they appear laminated
,ith layers of organic material covered ,ith concentric shells of calcified matter
The crystalline structure is chiefly hydroxyapatite and contains octacalcium
phosphate
The aetiology of a sialolith is varied %nflammation, local irritants,
antisialogogues etc are thought to play a significant role
Stones are a common etiologic factor for sialadenitis Mucous plugs,
strictures etc produce a similar clinical picture
)bout 9: ;: < occur in the submandibular gland or duct for the follo,ing
reasons
=harton0s duct contains sharp curves li"ely to trap mucin plugs or
cellular debris
+
5alcium levels are high in submandibular saliva
Dependent position of the gland
+ 1+ < of sialoliths occur in parotid gland and $ + < in sublingual and
minor salivary glands
5linically, the most common symptom of sialolithiasis is painful intermittent
s,elling in the area of a major salivary gland, ,hich ,orsens during eating and
resolves after meals The pain migrates from the bac"up of saliva behind the stone
or plug
Sialoliths of Stenson0s or =harton0s duct ,ill be palpable if present in the
peripheral portion of the duct The common site of calculus is buccal mucosa and it
presents as an asymptomatic ,ell circumscribed, freely movable draining s,elling
Diagnosis:
1 2rdinary radiography
$ Sialography
& 5T scan
Treatment:
)cute infections secondary to stasis should be treated ,ith antibiotics
Stones in the distal portion of duct can often be removed manually Deeper stones
re-uire surgery >ithotripsy has been described as a non*invasive method of
disintegrating sialoliths
Miscellaneous infections of salivary glands
Tuberculosis
Salivary glands may be primarily involved in tuberculosis, or the disease may
infect periglandular lymph nodes The parotid is most commonly affected The
clinical picture is of a firm, non*tender s,elling, resembling a tumour Draining
?
fistulae may be present Diagnostic investigation of chronic salivary gland
enlargement should include chest radiograph, s"in test and acid fast staining of
drainage and culture
Sarcoidosis (Heerfodts disease)
This is a chronic, systemic, granulomatous inflammation involving salivary
glands in ?: < of cases 4veoparotid fever occurs in 1: < of cases ,hich present a
triad of findings facial palsy, parotid enlargement and uveitis
Treatment is symptomatic care and long term corticosteroid therapy
Actinomycosis
)ctinomycosis israelii is a commonplace member of oral flora and may invade
the salivary glands Sialadenitis occurs in as high as 1: percent of cases of
orofacial actinomycosis >ong term high dose penicillin therapy is the treatment of
choice
Diagnosis of salivary gland infections
) detailed history and physical examination are useful in the diagnosis of
salivary gland infections The patient ,ho reports acute s,elling of a salivary gland
at meal time may be diagnosed as having an acute ductal obstruction 5hildren
should be -uestioned carefully for exposure to epidemic mumps in recent pasts
5areful inspection of oral cavity is mandatory to differentiate bet,een a
salivary gland s,elling and a space infection of dental origin 7hysical examination
must include gentle palpation of all major salivary glands and bimanual intraoral and
extraoral palpation of ducts
Diagnostic roentgenology may be useful %ndications for plain films or
sialography are
a# detection of strictures, calculi, foreign bodies
b# detection of large parenchymal abscesses
c# estimation of severity of parenchymal damage or residual function
@
%u$"urs "f salivary glands
Tumours of salivary glands constitute a heterogenous group of lesions of
great morphologic variations, and this presents difficulties in having a general
classification
Benign tumours
!leomorphic adenoma (mi"ed tumour)
This is the most common of all salivary gland tumours, constituting over +: <
of all the cases of tumours and about ;: < of all benign salivary gland tumours %t
is characterised by a morphologic and histologic complexity mar"ed by the presence
of a variety of cell types
'umerous theories have been advanced to explain the histogenesis of this
tumour, and the current arguments centre around the myoepithelial cell and a
reserve cell in the intercalated duct %t is said that the myoepithelial cell is
responsible for the morphologic diversity of the tumour, ,hile the intercalated
duct reserve cells can differentiate into ductal cells and myoepithelial cells, ,hich
can undergo mesenchymal metaplasia to give rise to more different types of cells

Clinical features:
9
The parotid is the most common site of pleomorphic adenoma !;: <# %t may
occur, ho,ever, in any gland and is more common in ,omen and in patients in (th to
?
th
decades The history is that of a small, painless, -uiescent nodule ,hich slo,ly
increases in size %t is usually an irregular nodular lesion ,hich is firm in
consistency 7ain is not a common symptom )mong the minor glands, the palatal
glands are fre-uently affected %t may cause difficulties in breathing, tal"ing and
mastication
Histology:
The tumour is al,ays encapsulated The diverse histologic pattern is
characteristic Some areas present cuboidal cells arranged in duct*li"e pattern ,ith
an eosinophilic coagulum %n other areas, the tumour cells may assume a stellate,
polyhedral or spindle shape Some may even sho, chondroid or osseous character
Treatment:
The accepted treatment is surgical excision The tumour and the involved
lobe are removed %ntra*oral lesions may be treated more conservatively by
extracapsular excision Malignant transformation may occur in a long*standing
untreated tumour or in a recurrent one
#onomorphic adenoma
=.2 classification of monomorphic adenomas subdivides them into
1# adenolymphoma !=arthin0s tumour#
$# oxyphilic adenoma
&# others, ,hich includes tubular, alveolar !trabecular#, basal cell and clear cell
adenomas
;
Adenolymphoma (Warthins tumour)
This unusual type of tumour is found almost exclusively in the parotid gland
This exhibits a definite predilection for men and for age groups of (
th
, +
th
and ?
th

decades

The tumour is generally superficial, lying just beneath the parotid capsule or
protruding through it %t usually does not gro, more than & ( cm in diameter it is
painless, firm to palpation and is clinically indistinguishable from other benign
lesions
.istologically, the tumour consists of t,o components epithelial and
lymphoid tissue %t is essential an adenoma exhibiting cyst formation, ,ith papillary
projections into the cystic spaces and a lymphoid matrix sho,ing germinal centres
The currently accepted theory of histogenesis is that the tumour arises in
salivary gland tissue entrapped in paraparotid or intraparotid lymph nodes during
embyogenesis
The treatment is surgical excision of the tumour
Oxyphilic adenoma (oncocytoma / acidophilic adenoma)
This is a rare tumour usually occurring in the parotid gland it is more
common in ,omen and in elderly persons %t does not gro, to great size and is
clinically not different from other benign tumours
1:
Microscopically, the tumour is characterised by large cells ,ith an
eosinophilic cytoplasm and a distinct cell membrane, and ,hich tends to be arranged
in narro, ro,s or cords These tumour cells resemble the apparently normal cells
called Aoncocytes0, ,hich are usually seen in a great number of locations in the body
The treatment of choice is surgical excision The tumour does not tend to
recur and malignant transformation is uncommon
Basal cell adenoma
This tumour occurs usually in major salivary glands and a majority of patients
are over ?: years of age %t presents as a painless slo,*gro,ing lesions
.istologically, it has a ,ell*defined connective tissue capsule, and the cells are
isomorphic and basaloid in appearance ,ith basaloid round to oval nuclei The cells
bear similarity to the secretory cells of intercalated duct The basal cell adenoma
is treated by excision
Canalicular adenoma
This occurs in intra*oral accessory salivary glands, mainly in the upper lip
7atients are usually over ?: years of age %t presents as a slo,*gro,ing, painless,
non*fixed nodule of the lip .istologic presentation is of cords of epithelial cells,
arranged in a double ro, The canalicular adenoma is treated by simple excision
Myoepithelioma
%t occurs in adults and the parotid gland is the commonest site of
occurrence The commonest intra*oral site is the palate The tumour is composed of
11
spindle*shaped or plasmacytoid cells or a combination of the t,o, set in a
myxomatous bac"ground Definitive diagnosis lies in ultrastructural identification of
myoepithelial calls The lesion is treated by excision
Ductal papillomas
7apillomas arising from excretory ducts of salivary glands present in three
forms
1# Simple ductal papilloma an exophytic lesion ,ith a papillary surface and a
pedunculated base
$# %nverted ductal papilloma presents as a nodule of the oral mucosa
&# Sialadenoma papilliferum exophytic gro,th of hard palate
)ll types are treated by excision
Benign lymphoepithelial lesion
This common lesion exhibits both inflammatory and neoplastic character
The lesion is manifested essentially as a unilateral or bilateral engagement of the
parotid and 8 or submandibular glands ,ith mild discomfort, occasional pain and
xerostomia
%t is considered to be an auto*immune disease in ,hich the salivary gland
tissue becomes antigenic There is often a diffuse, poorly outlined enlargement of
the gland rather than the formation of a discrete nodule .istologically, there is an
orderly lymphocytic infiltration of gland tissue, destroying or replacing the acini
The condition has been treated by both surgical excision and radiation 1ut
the latter is not used no, in vie, of the possibility of radiation induced malignancy
$elation to #i%ulic&s disease
The disease originally described by Mi"ulicz in 1;99 ,as characterised by a
symmetric or bilateral chronic, painless enlargement of the lacrimal and salivary
glands Mi"ulicz0s patient manifested a benign course ,ithout lymphatic
involvement Some later ,or"ers noticed that certain cases diagnosed as Mi"ulicz0s
1$
disease often ran a rapidly fatal course These ,ere later proved to be malignant
lymphomas
%t is no, believed that Mi"ulicz0s disease and the benign lymphoepithelial
lesion are identical in nature
Malignant tumours
#alignant pleomorphic adenoma
This term includes those histologically benign tumours ,hich are sho,n to
have metastases resembling the primary lesion, as ,ell as those ,hich clinically
resemble benign pleomorphic adenoma but exhibits cytologically malignant changes
There is considerable debate as to ,hether they arise from an earlier benign lesion
or they represent a malignant lesion from the onset
There is no obvious clinical difference bet,een benign and malignant
pleomorphic adenomas, except an occasional fixity to deeper structures and
increased incidences of surface ulceration, pain and regional lymph node
enlargement in malignant cases 3re-uent metastases to lungs, bones, viscera and
brain are seen
1&
.istologically, the malignant component may overgro, the benign one or may
stay localised in discrete locations 'uclear changes, invasion of connective tissue,
focal necrosis etc are the features used to determine malignancy
The treatment is essentially surgical, and recurrent lesions are managed by
combined surgery and radiotherapy
Adenoid cystic carcinoma
This is a form of adenoid carcinoma, ,hich fre-uently affect intra*oral
accessory salivary glands, parotid and submaxillary glands 5linical manifestations
include local pain, facial paralysis !in case of parotid involvement#, fixity to deeper
structures, local invasion and surface ulceration .istologically, the tumour is
composed of small, deeply staining uniform cells resembling basal cells, arranged in
duct*li"e pattern, the central portion of ,hich contain a mucoid material spread of
tumour cells along the perineural spaces or sheaths is a common feature
The treatment is chiefly surgical, but it is often coupled ,ith radiation This
tumour usually metastasises only late in its course and hence long*term follo,*up is
mandatory
Acinic cell carcinoma
This lesion is peculiar in that the cells sho, acinar cell differentiation
instead of the duct*li"e pattern seen in other tumours %t closely resembles
pleomorphic adenoma in gross appearance %t is reported occurring chiefly in the
parotid )cinic cell carcinoma is composed of cells of varying degrees of
1(
differentiation =ell*differentiated cells resemble normal acinar cells >ymphoid
elements are also commonly seen
The treatment is essentially surgical The recurrence rate is 9 +;<, ,hich
occurs many years after surgery >ong*term follo,*up is necessary
#ucoepidermoid carcinoma
This is an unusual type of salivary gland tumour, described as a separate
entity in 1;(+ by Ste,art, 3oote and 1ec"er Majority of cases occurred in parotid
2ther gland also may be affected This tumour has a lo,*grade malignant variety
and a high*grade malignant type The former appears as a slo,ly enlarging painless
mass 1ecause of the tendency to develop cystic areas, intra*oral lesions resemble
mucocoele The tumour of high*grade malignancy gro,s rapidly and produce pain and
facial nerve paralysis
The mucoepidermoid carcinoma is not encapsulatedB it infiltrates into the
surrounding tissue and sho, metastases .istologically, this is a pleomorphic tumour
composed of mucous*secreting cells, epidermoid*type cells and intermediate cells
The treatment is surgical /ecent data has sho,n favourable response to
radiation therapy >o,*grade malignant type can be managed by surgery alone
Clear cell carcinoma
This is a relatively recently recognised lesion, characterised by the presence
of peculiar Aclear cells0 ,hich are thought to arise from intercalated duct cells or
myoepithelial cells This lesion is also found mainly in major glands, especially
parotid 5lear cell carcinoma tends to occur in elderly adults and in females 5linical
presentation is not different from other tumours .istology sho,s clusters of clear
cells surrounded by a thin septum of fibrous connective tissue The lesion is
treated by surgery %t usually sho,s a relatively favourable prognosis
1+
'pidermoid (s(uamous cell) carcinoma
This tumour involves a grave prognosis, since it exhibits infiltrative
properties, metastasises readily and recurs readily %t may arise in any salivary
gland %t seems to be of ductal origin, since the ducts undergo s-uamous metaplasia
,ith ease ) combination therapy of surgery and radiotherapy is indicated
Salivary gland inv"lve$ent in rheu$ati# disease
) salivary gland s,elling, especially of the parotid, can be a manifestation of
auto*immune disease The distinct subsets of auto*immune salivary gland disease
are
1# allergic sialadenitis,
$# SjCgren0s syndrome 8 myoepithelial sialadenitis and
&# Dpithelial cell sialadenitis 8 granulomatous sialadenitis
Allergic sialadenitis
This is an acute, but rare, condition Deposition of antigen*antibody
complexes ,ithin the parenchyma results in glandular s,elling /emoval of allergen
is curative The allergens include certain foods and drugs such as phenyl butazone
and nitrofurantoin
1?
#yoepithelial sialadenitis (S)*grens syndrome)
This is a condition originally described as a triad consisting of
"eratoconjunctivitis sicca, xerostomia and rheumatoid arthritis Some patients
present only ,ith dry eyes and dry mouth !primary SjCgren0s syndrome 8sicca
complex# ,hile others develop other collagen vascular diseases li"e S>D,
polyarteritis nodosa, scleroderma and rheumatoid arthritis !secondary SjCgren0s
syndrome#
The disease occurs predominantly in ,omen over (: years of age The clinical
diagnosis re-uires a combination of t,o of the classical triad Dryness of eyes and
mouth cause grittiness and pain in eyes, and pain and burning sensation of oral
mucosa 2ral candidiasis, rampant caries and fissured tongue are common 7atients
often have bilateral parotid involvement 2ther glands also may be affected
Mi"ulicz0s disease is thought to be synonymous ,ith the salivary component
of SjCgren0s syndrome The lesion may have extra*glandular manifestations li"e
lymphomas
.istologically, intense lymphocytic infiltration of salivary glands and
proliferation of ductal epithelium are seen )ntiductal antibodies may be present in
the serum of the patients 2ther factors li"e the rheumatoid factor and
antinuclear antibodies are also common DS/ may rise to 9:<
Sialography may be of diagnostic value in SjCgren0s syndrome %t sho,s a
typical Acherry*blossom0 !branchless fruit*laden tree# appearance
There is no satisfactory treatment to SjCgren0s syndrome The patients are
treated symptomatically ,ith artificial tears and salivary substitutes
1@
Mis#ellane"us diseases
Cystic fibrosis
This condition is transmitted as an autosomal recessive trait and is the most
common lethal genetic syndrome among ,hite children The children suffer from
chronic pulmonary disease, pancreatic insufficiency and elevated concentration of
electrolytes in s,eat
Though mucous*secreting glands are more pathologically involved, parotid
saliva is also slightly affected The elevation of calcium and protein levels in the
glands results in the turbidity of secreted fluid o,ing to the formation of calcium*
protein complexes
+ecrotising sialometaplasia
'ecrotising sialometaplasia is a benign inflammatory reaction of salivary
gland tissue, ,hich both histologically and clinically mimics malignancy The most
li"ely cause is local ischaemia, the cause of ,hich is not "no,n though alcohol and
tobacco abuse have been implicated by some ,or"ers
The condition occurs more commonly in men Most patients are in (
th
and +
th

decades Most cases occur in palate, but other intra*oral sites have also been
noticed The lesion generally presents as an ulcer 7ain is not common S,elling may
present in some cases
'ecrotising sialometaplasia is histologically characterised by ulcerated
mucosa, pseudoepitheliomatous hyperplasia of the mucosal epithelium, acinar
necrosis and s-uamous metaplasia of salivary glands
The lesion is essentially self*limiting and heals by secondary intention
#ucous retention phenomenon (mucocoele)
This is generally conceded to be of traumatic origin, and is a common lesion
%t may be caused by traumatic severance of a salivary duct, or a chronic partial
19
obstruction of a salivary duct Thus mucocoeles may be classified into extravasation
type and retention type The former is more common
The condition occurs more commonly in lo,er lip The lesion may lie fairly
deep in the tissue or be exceptionally superficial The superficial lesion is a raised,
circumscribed vesicle ,ith a bluish, transparent cast and is less than 1: mm in
diameter The deeper lesion is also a s,elling, but the colour and surface
appearance are of normal mucosa The contents usually consists of thic", mucinous
material
.istology sho,s elevation of mucosa, thinning of epithelium, ,all made of a
lining of compressed fibrous connective tissue and a lumen filled ,ith an
eosinophilic coagulum, containing variable cells
The treatment is excision of the lesion along ,ith the removal o f the
associated salivary gland acini
$anula
This is a form of mucocoele ,hich specifically occurs in the floor of the
mouth in association ,ith =harton0s duct or sublingual ducts The aetiology and
pathology are essentially the same as for mucocoele of other glands
The lesion develops as a slo,ly enlarging painless mass on one side of the
floor of the mouth Since the lesion is deep*seated, overlying mucosa is normal in
appearance %f it is superficial, the mucosa ,ill have a translucent bluish colour
Treatment is to unroof the lesion to drain the contents
I$aging in salivary gland diseases
Multiple imaging techni-ues may be used in the diagnostic evaluation of
salivary gland These range from plain radiographic examination to the most
complex magnetic resonance imaging !M/%#
1;
!lain radiography
7lain radiography still serves an important function in the examination of the
salivary glands %t is indicated to identify any radio*opa-ue sialoliths, phleboliths or
dystrophic calcification present in the gland or duct
3or evaluation of parotid gland, 7) vie,, true lateral and lateral obli-ue
vie,s ,ith the chin extended and mouth open, should be performed 3or evaluation
of submandibular gland, the lateral vie, radiograph should be ta"en ,ith index
finger pressing the tongue do,n %n addition, an intra*oral occlusal vie, may be
helpful
)bout 9:< of salivary calculi can be visualised ,ith plain radiography They
appear as focal calcific densites, most commonly associated ,ith submandibular
gland
+uclear medicine (radionuclide imaging)
The findings of nuclear medicine techni-ues are less specific than
sialography, 5T or M/% 1ut this may be useful as an adjunct to these techni-ues
%ntravenous injection of 1: m5i of Tc*;;m pertechnate is performed ,ith
gamma camera images obtained every $ minutes )bnormalities may be defined as
increased, decreased or absent upta"e of radionuclide %ncreased upta"e is seen in
sialadenitis and granulomatous diseases and in oncocytoma and =arthin0s tumour
Decreased upta"e is seen in ageing, viral infections and most tumours
,ltrasonography
This provides a non*invasive means for examination of the salivary glands,
,ith the exception of the deep lobe of parotid The differentiation bet,een cystic
and solid compartments can easily be made 3luid*filled structures ,ith no tissue
interfaces, such as an abscess or cyst, appear echo*free on ultrasound studies
Solid structures, such as heterogeneous tumour, appear filled ,ith multiple echoes
and various shades of grey
$:
.igh fre-uency transducers in the order of @+ M.z are used Se-uential
images in transverse and longitudinal planes are performed 4ltrasonography may be
used in the evaluation of all types of pathology ,ithin the salivary glands %n the
case of inflammatory lesions, the chronicity of the process determines the
sonographic pattern
Sialography
Sialography is the direct radiographic demonstration of the salivary gland
and duct system by injection of radio*opa-ue contrast material into the ductal
orifice The three main indications for the performance of sialography are
!i# sudden acute s,elling of a gland possibly secondary to ductal obstruction by
a stone or stricture,
!ii# progressive glandular enlargement or symptoms suggesting recurrent
inflammation,
!iii# palpable salivary gland masses
Techni(ue:
7rior to canulation of the duct, conventional radiographic examination is
indicated to determine the radiographic vie, 'o premedication or local anaesthesia
is re-uired for sialography )fter placement of cannula in the duct, an oily contrast
material such as ethiodol is introduced by either hydrostatic pressure or gentle
intermittent manual injection 5ontrast injection is performed under fluoroscopic
$1
guidance The gland should be visualised during ductal filling, acinar filling,
evacuation and post*evacuation stages
-indings:
%n chronic inflammatory sialadenitis, focal dilatation of peripheral ducts and
globular or sacular collections of contrast are noted in an irregular pattern
throughout the gland Delayed contrast evacuation is noted
%n auto*immune diseases, punctate or globular collections of contrast
material is homogeneously seen throughout the gland, and these do not disappear
during evacuation SjCgren0s syndrome is characterised by a Acherry*blossom0
!branchless fruit*laden tree# appearance
%n evaluation of calculi, plain radiography is superior to sialography since
most calculi are radio*opa-ue, and the contrast may obscure it Eranulomatous
diseases and lymphoma has a similar sialographic appearance The findings have a
progressive nature depending on the course of the disease Sialography may also be
used to evaluate lacerations or haematoma formations
Sialography is contra*indicated in cases of
!i# acute infection and
!ii# history of allergy to the contrast medium
Computed tomography (CT)
The primary indications of 5T evaluation include masses or generalised
enlargements of one or more glands, acute inflammatory processes or abscesses
This techni-ue is helpful in diagnosis, treatment planning and in evaluating response
to the treatment
/outine 5T may be performed ,ith or ,ithout intravenous contrast
administration The 5T has a 1:*fold advantage over conventional radiographs in the
detection of calcifications ,ithin the glands )cute and chronic inflammation,
benign and malignant tumours and cysts can be visualised %n the case of malignant
$$
tumours, infiltration to surrounding tissues may be seen )lso, facial nerve and
other associated structures may be visualised, and this aid in treatment planning
#agnetic resonance imaging (#$.)
The indications for 5T and M/% overlap M/% is the examination of choice
for the evaluation of neoplastic lesions The advantages of M/% include increased
soft tissue contrast at the margins of the tumour The major disadvantages include
the high cost, limited availability of facilities and increased technical complexity
M/% examination of salivary glands uses a superconducting magnet ,ith a
field*strength of 1+ T /outine examination includes slice thic"enings of + mm or
less The M/ appearance of pleomorphic adenoma and =arthin0s tumour is
inhomogeneous ,ith lo, signal intensity compared to the normal gland %n =arthin0s
tumour, cystic components are encountered 3ibrosis or calcifications appear as
areas of lo, signal or signal void Malignant tumours sho, a lo,er intensity signal
than that of benign tumours .aemorrhagic spots appear as high intensity images
The use of M/% in salivary gland disease is limited because many diseases
sho, similar patterns The contra*indications to M/% include pacema"ers,
ferromagnetic valvular clips and implanted neurostimulation devices
$&
Surgi#al Manage$ent "f Salivary &land Diseases
=ith the possible exception of surgical management of retention cysts li"e
mucoceles and ranulas, transoral sialolithotomy is the most fre-uent operation
performed on salivary system This is a simple operation often but overloo"ed by
the medical practitioner untrained in oral surgery in favour of enucleation of the
gland %f the stone is favourably located, its removal through the mouth preserves
the gland and hence its function
The submandibular gland can be enucleated ,ithout harmful se-uelae if the
operation is properly accomplished %n most patients ,ith normal salivary secretion
in the remaining glands its removal is of no conse-uence
.o,ever parotid gland is of greater concern Danger to the facial nerve is
al,ays present although careful surgery permits removal of this gland ,ith only
transient ,ea"ness in most instances
/emoval of either gland ,ill result in a significant facial deformity .o,ever
these factors are most significant if operation is necessary but contraindicate such
procedures ,hen conservative methods ,ould suffice
Tumours involving the parotid, submandibular, sublingual or minor salivary
glands located in the chee", lips palate may also ,arrant their removal in certain
instances Such procedures have been discussed in detail belo,
Submandibular sialoliths
Submandibular gland lithiasis is the most common disorder of submandibular
gland and most fre-uent location being extra glandular Despite the fact that these
calculi are large they are rarely painful since lumen of =harton0s duct is larger and
more expandable than the Stenson0s duct 4sual symptoms are pain and sudden
gland enlargement during eating 4sually there is return of function in most
patients after removal of sialolithiasis
$(
Those located in the anterior part of the duct
4sually stones located anterior to the second mandibular molar are best
removed under local anaesthesia Those lying anterior to a line joining mesial
surfaces of second molars are designated as anterior calculi
7reoperative assessment of anterior calculi depends on history, clinical
examination and plain radiographs 4sually a preoperative sialogram is not indicated
because of the possibility of the stone being propelled into a more posterior part of
the duct by the force of the injection
Procedure
) suture is passed around the duct posterior to the stone to prevent its
posterior dislodgement during manipulation after passing one suture into the floor
of the mouth to test the tissues up for easy passage of the circumductal suture
Duct can be easily located by bisecting the angle formed by the sublingual plica and
the line attachment of the tongue
The circumductal suture is then secured to a haemostat and placed over the
adjacent teeth resulting in "in"ing of the duct ) second suture is then placed
bet,een the submandibular duct papilla and frenum Eentle traction applied to
these sutures ,ill ma"e tissues at surgical site taut thereby allo,ing mucosa to be
cut easily
%ncision is made along the line of the duct over the stone Scalpel should not
be plunged deeply but should only divide the mucous membrane and enter just into
the underlying tissues The duct is then uncovered by both blunt and sharp
dissection ,ith a fine pointed scissors through the loose connective tissue al,ays
being a,are of sublingual veins lingually %t is then mobilised 3re-uently at this
stage the calculus is visible through the duct ,all and by a longitudinal incision, it is
released %f it is adherent to the duct ,all, then it is slo,ly released ,ith a small
curette ,ithout further damaging the duct
$+
) fe, interrupted sutures at the floor of the mouth then close ,ound
Ductal incision is not sutured to prevent formation of a stricture
Those located in the posterior part of the duct/
These are best removed under general anaesthesia, as fe, patients ,ill
tolerate retraction re-uired under local anaesthesia
)n obstruction sufficient to cause symptoms can occur in any one of the t,o
,aysF * stone may increase to such a size that only a minimal amount of saliva can be
secreted or an infection may set in
%f the stone is not visible on a central occlusal film, then it is not feasible to
remove it by the method used for anteriorly placed stones and it must be treated
as a posteriorly placed stone or an intraglandular stone Majority of the posterior
stones can be vie,ed in a posterior obli-ue occlusal film This is supplemented ,ith
an obli-ue lateral ja, film so that its position relative to the mandible can also be
assessed .o,ever the best means of locating its position and status of the gland is
by sialography %f it depicts a G sausage string appearanceH in the sialogram a good
chance of recovery exists =hen the intraglandular ducts are irregular, grossly
dilated and cavitated then removal of the gland is the best choice
Procedure
1est done under general anaesthesia Tongue is retracted side,ays )
lacrimal probe is inserted via the ductal orifice and elevated to assist in locating
the duct and then mucosa is excised in the premolar region Duct is identified and
dra,n for,ards using a suture passed around it Duct is then follo,ed posteriorly
and lingual nerve identified ,here it crosses beneath the duct 2nce lingual nerve is
identified then initial incision is enlarged, lingual nerve is mobilised laterally and
retraction sutures passed to expose the surgical site
)n assistant then pushes the lo,er pole of the gland up,ards so that the
upper pole is brought into vie, ) suture is then passed over posterior margin of
$?
mylohyoid to retract it for,ard %f the stone is visible, it is delivered via a
longitudinal incision %f not duct is opened at most li"ely location and explored until
recovered =ound is then irrigatedB retraction sutures removed and incised duct
left open, mucosal tissues are then closed ,ith interrupted sutures
Those located in intraglandular position of the submandibular duct/
.ere the entire gland is removed %f the stone is a chance finding and is
small, asymptomatic and sialographically normal, it can be left in place and observed
for any changes in its location or function of the gland )ny change for the ,orse
indicates the need for gland excision
Procedure
) t,o*inch long convex incision is made parallel to s"in crease, approximately
1+*$cm belo, the inferior border of mandible
%ncision deepened do,n through superficial cervical fascia, reflected
inferiorly, anterior facial vein identified and divided bet,een ligatures )n upper
flap of connective tissue is then raised close to the gland surface thus protecting
any branches of facial nerve raised along ,ith the flap
The facial artery is found by dissecting and then retracting the lo,er pole
of the gland up,ards and for,ards The posterior belly of digastric is identified
and it along ,ith the stylohyoid is retracted do,n and bac" The facial artery is
seen passing behind the muscle to,ards the gland %t is clamped and divided, then
ligated
Then the anterior aspect of the lo,er pole of the gland is reflected up,ards
and bac",ards Through finger dissection and "eeping close to the gland, a covering
of loose connective tissue is maintained over the hypoglossal nerve that lies medial
to the gland
The gland is then pulled do,n,ards, exposing the I*shaped fold of
connective tissue containing the lingual nerve and submandibular duct These t,o
$@
structures are then dissected out ,ith care )t this stage one should be able to
clearly delineate three basic structures medial to the gland namely lingual nerve
superiorly, duct centrally and hypoglossal nerve inferiorly
'o, only the duct and deep part of the gland still remain attached The
posterior border of the mylohyoid is retracted and a branch of the sublingual
artery ligated Then the submandibular duct is clamped, divided and double ligated
so that only a short stump remains
Tissues are then closed in layer, a drain inserted if necessary and a pressure
dressing applied
Parotid sialoliths
Stensen0s duct is the location of ?*1:< of salivary calculi 2f
these (:< are opa-ue They are seen at ( basic locationsF *
%mpacted in the papilla
%n the sub mucous part of the duct
%ntraglandularly
%n the extra glandular part of duct external to the buccinator
Those in the papilla and submucous part of the duct
5alculi in this location can be released by slitting the papilla 2ne blade of a
pair of fine sharp pointed scissors is inserted a portion of the ,ay into the duct
and a small cut is made bac",ard from the orifice 4sually the calculus pops out as
soon as the blade of scissors is removed, if not then gentle pressure on the gland
,ill force out the calculus along ,ith a -uantity of saliva The ,ound heals rapidly
$9
Those located e"traglandularly e"ternal to the buccinator 0
5alculi located in this region can be approached via an incision in the intra*
oral aspect of the chee" %njection of a local anaesthetic ,ith a vasoconstrictor ,ill
reduce bleeding and also raise the mucous membrane off the surface of buccinator
to aid in soft tissue dissection ) traction suture is placed anterior to the papilla, a
4*incision is made through the mucosa, and the triangle containing the papilla and
the duct is then raised off the buccinator 4pper and lo,er flaps are mobilised and
stay sutures placed to hold them out of the ,ay Dissection is proceeded until the
point ,here the duct pierces the buccinator is reached The superior and inferior
margins of buccinator dehiscence are identified and traction sutures placed at each
margins and retracted to enlarge the dehiscence Then duct is traced laterally and
retracted medially into the mouth ,ith a suture =ith this approach calculi in a
large portion of Stenson0s duct can be removed easily even ,ell outside the
masseter musculature 2nce calculi are located, adhesions to tissues around are
dividedB longitudinal incision made over the duct and stone removed The duct is not
sutured but tissues around are closed ,ith absorbable sutures
Those located in the intraglandular portion of the duct /
Stones located intraglandularly cannot be reached by an intraoral approach
) parotidectomy type incision is recommended S"in and subcutaneous tissues are
raised from deep fascia covering the gland until its anterior border is uncovered
Then deep fascia is incised horizontally over the supposed portion of the duct Duct
at this point lies on a line joining the angle of mouth and ala of nose The buccal
branch of facial nerve usually lies on its surface and transverse facial vessels
usually lie about 1cm higher than the duct
2nce duct is identified, it is then traced bac" into the gland 1ranches of
facial nerve tend to cross immediately superficial to the duct and must be
preserved =hen the section containing the calculi is reached it is incise
longitudinally in the usual ,ay and delivered after passing necessary sutures in
front and behind the stone around the duct to prevent slippage 5apsule of the
gland is closed ,ith continuous fine plain catgut and s"in incision is closed in layers
,ith a vacuum drainage
$;
Tumours of salivary glands
Salivary gland neoplasms are uncommon and account for less than &< of all
tumours of head and nec" region 2f these tumours about @+*9+< occur on parotid,
1:*$:< in minor salivary glands, most commonly in palate !+9<#, tongue !1:<# and
upper lip !;<#
Sublingual gland has the highest ratio of malignant to benign neoplasms %n
fact 9:< of parotid, ?+< of submandibular, +:< of minor salivary and $:< of
sublingual gland tumours are benign
The only curative treatment of salivary gland tumours is surgical extirpation
/esection of parotid gland tumours is complicated by the presence of facial nerve
,ithin the gland =ith the exception of =arthin0s tumours, enucleation of parotid
tumours is not advised Mixed tumours are often poorly encapsulated and malignant
tumours often invade surrounding glandular tissue, hence ade-uate margins of
normal salivary tissue must be resected to reduce the chances of local recurrence
Total resection of submandibular gland is the preferred treatment for all
submandibular neoplasms Minor salivary gland neoplasms of palate or mucosa
fre-uently involve periosteum or bone and hence portions of these must be included
along ,ith the surgical excision
!arotidectomy 1ith the preservation of facial nerve
This operation is also called superficial or conservative parotidectomy
Superficial parotidectomy is used to describe the removal of the gland superficial
to facial nerve 1ut both superficial and deep parts can be removed as necessary
,ith preservation of facial nerve
)fter ade-uate preparation of surgical site, a solution of 1 in $::,::: parts
adrenaline in saline is injected under the s"in over the parotid anterior to external
ear and close against external auditory meatus 'ot more than 1:ml is injected
&:
%ncision starts ,ithin the hairline above and anterior to the auricle and is
ta"en do,n and bac" to free margins of tragus, follo,s it and under its cover is
carried in a gentle curve over the mastoid to join a convenient s"in crease passing
do,n and for,ards into the nec" behind the mandible
%ncision in the nec" crease is deepened first, dividing the platysma until the
deep fascia is reached The great auricular nerve is then identified as it crosses
the posterior border of sternomastoid to lie in the ,ound about 1cm belo, and 1cm
in front of the lobe of the ear, immediately belo, the deep fascia, branching over
the gland surface The nerve ,ith the branches is tuc"ed under the lo,er edge of
the ,ound to "eep it moist
2nce deep fascia is identified the rest of the ,ound is deepened to this
level and s"in reflected for,ards from it 2ften one or more facial branches ,ill be
identifiable through translucent deep fascia as they emerge from anterior border
of the gland They are uncovered by opening the fascia, each branch is identified,
labelled by under running it ,ith blac" sil" and ends of it are clamped in mos-uito
artery forceps
The main trun" of the facial nerve lie further deeper do,n in the angle
bet,een bony external auditory canal and anterior surface of mastoid process %t is
found by separating lo,er pole of gland from anterior border of sternomastoid and
from mastoid process and cartilaginous part of external auditory meatus 7arotid is
retracted for,ards as dissection proceeds and the nerve is identified as it emerges
in the angle bet,een tympanic bone and anterior border of the mastoid process and
just superior to the upper border of the posterior belly of the digastric The
stylomastoid branch of posterior auricular artery passes superficial to the nerve to
enter the stylomastoid foramen and rough instrumentation can tear this small
vessel causing haemorrhage
Since the facial nerve and its branches are invested by loose connective
tissue and lie in tunnels ,ithin the parotid, they are freed by introducing the tip of
&1
the blades of a curved mos-uito artery forceps and opening it after ,hich a short
length of the gland substance mat be cut through ,ith scissors to expose the gland
The nerve trun" travels laterally ,ithin the parotid, passing around posterior
border of mandible and just belo, the nec" of the condyle before it splits into an
upper temporofacial and cervicofascial division Eenerally it is better to follo, the
lo,er division first and trace the cervical or at least marginal mandibular branch
anteriorly to a point in front of the parotid, hence the lo,er pole is mobilised after
,hich progressing up,ards branch by branch, further mobilisation is achieved
Those branches that pass into the tumour must be divided and the point at ,hich
they emerge identified and divided and both ends are tagged for subse-uent repair
%nterconnecting branches joining t,o peripheral branches vertically should
be conserved if possible %n general nerve passes superficial to retromandibular
veinB careful mobilisation of both nerve and vein ,ith division and ligation of the
latter is needed Tiny veins are sealed by diathermy
3or pleomorphic adenomas a margin of about half a cm of apparently normal
tissue should be removed around palpable mass as the tumour is lobulated and some
of these lobules may be left behind if dissection passes too closely >o,*grade
mucoepidermoid tumours or acinic cell tumours should be removed ,ith a some,hat
greater and more uniform margin
2nce tumour is removed, the ,ound is flushed liberally ,ith saline and
haemostasis chec"ed 1ranches of facial nerve may be repaired ,ith grafts if
necessary from great auricular nerve ) vacuum drain is then passed out through
the s"in belo, the earB ,ound is closed in layers and light pressure dressing applied
Total parotidectomy
This is indicated ,henF *
) slo, gro,ing mass not clinically malignant is present in deeper parts
&$
=hen a small neoplasm is recognised clinically as malignant and to secure
necessary margin, removal of ,hole gland is planned
>arge tumour in deep part of parotid gland presenting as a s,elling of the
soft palate !often dumb*bell in shape ,ith isthmus lying in the gap
bet,een styloid process and bac" of mandible#
Procedure
) s"in flap is raised in usual ,ay, but incision in the nec" s"in crease is
continued as far for,ard as the first molar region 3acial nerve is dissected outB
periosteum is then divided at lo,er border of angle of mandible and masseter
elevated from bone ) vertical cut similar to that used for vertical sub sigmoid
osteotomy is made just behind the mandibular foramen, medial pterygoid is then
freed from posterior fragment, ,hich is then displaced for,ards, lateral to
anterior fragment This opens up the interval bet,een the styloid process and
mandible
>o,er pole is then mobilised and digastric and sytlohyoid follo,ed bac" to
their origins, divided and turned for,ards Dxternal carotid emerging above the
muscles is identified and divided and ligated
)t this stage mouth is uncovered and entered ) solution of adrenaline
1F$::,::: in saline is injected into soft palate over s,elling and a vertical incision,
circumscribing any previous biopsy scar is made Ddges are undermined leaving a
thin layer of muscle and connective tissue over the tumour Mass is freed ,or"ing
through both ,ounds Ereat care is exercised above and particularly behind the
lesion for fear of damaging the internal jugular vein or internal carotid artery, both
of ,hich lie deep to styloid process
3ollo,ing removal, ,ound is irrigatedB oral tissues are closed ,ith chromic
catgut The mandibular fragments are then ,ired together 7reauricular ,ound is
closed in layers and drainage established
&&
!arotidomandibulectomy
This is indicated ,hen there is invasion of mandible by a malignant neoplasm
Procedure !
)fter preparation of surgical site, a s"in flap is raised as for excision of a
benign neoplasm of the deep part of parotid Eland is then mobilised posteriorly and
inferiorly and main trun" of facial nerve identified )s many branches are dissected
out as possible, sometimes sacrifice of the ,hole nerve may be necessary
'ext the TMJ capsule is opened, and condyle mobilised Masseter is
separated from the zygomatic arch and mandible is divided in the third molar
region 7arotid and mandibular ramus are tilted up and for,ard and separated from
the styloid process and its attachment muscles Then further elevation of the
ramus is possible after ,hich the origin of the medial pterygoid muscle from the
tuberosity is palpated and separated 1efore this is done the external carotid is
identified ,here it emerges from behind the stylohyoid and enters the deep part
of the gland %t is first ligated and transected to prevent troublesome
haemorrhage from maxillary artery as the medial pterygoid is sectioned
Strong do,n,ard traction ,ill no, permit separation of the insertion of
temporalis into the coronoid and lateral pterygoid to the condyle )s hemostasis is
completed the maxillary artery is sought and ligated 3acial nerve is repaired using
great auricular nerve as graft ) bone graft can then be placed unless a
postoperative course of radiotherapy is to be employed =here a bone graft does
not replace ramus, patient ,ill be left ,ith a deep depression in front of the ear,
but this can be covered by a suitable hairstyle There ,ill be a tendency for the
mandible to s,ing to,ards the affected side and hence early training is needed to
overcome this problem
&(
%f condyle is invaded, then articular fossa and eminentia can also be
removed Styloid process and muscles can also be excised to increase the margins,
but should be done after resection of the main mass
Temp o roparotidectomy
Small*scale resection of external auditory canal may be included ,ith
excision of pinna and overlying s"in of parotid ,hen these structures are involved
The mastoid process can also be detached ,ithout much difficulty, thus exploring
facial trun" to ma"e suturing and nerve grafting easy
Dxtension of a parotid neoplasm bac" into bone is therefore amenable to
excision of parotid gland, mandibular ramus and TMJ together ,ith temporal bone
.o,ever the operation carries high ris" for the need to section dense bone and
separate it from internal carotid artery, internal jugular vein and sigmoid, superior
and inferior petrosal sinuses )de-uate cover needs to be provided for the dura as
the ,ound is closed The hypoglossal nerve is mobilised and anatomised to the
peripheral branches of facial nerve at the end of the operation
!arotidectomy in continuing 1ith nec% dissection
) radial nec" dissection should be performed ,here cervical lymph nodes are
involved or ,here there is a mass at lo,er pole of parotid due to an aggressive
tumour of much size that invasion of upper cervical nodes cannot be excluded
5onsideration should be given to pre*operative radiation of the nec" to a dose of
(::*+:: rads
'"tracapsular e"cision of submandibular salivary gland
There is a great incidence of recurrence for the submandibular gland than
for the parotid after excision of slo, gro,ing neoplasm li"e pleomorphic adenomas
The gland is removed together ,ith its investing fascia, ,hich is separated
from the anterior and posterior bellies of digastric and stylohyoid muscle The
hypoglossal nerve is identified and preserved The facial artery is identified ,here
&+
it emerges from under the cover of the stylohyoid and again on the lateral surface
of the mandible Marginal mandibular nerve is isolated and preserved and then
fascia divided at the lo,er border of the mandible Eland is freed off the
mylohyoid muscle anteriorly and the angular tract of fascia posteriorly
%f the lingual nerve is involved in the tumour mass then it is sectioned in
front of and behind the gland and cut ends sutured %f a greater margin of tissue
than the immediate capsule is needed laterally then the periosteum of the mandible
is divided at the lo,er border and stripped up from the submandibular fossa The
duct is divided close behind the papilla and the ,ound closed in layers ,ith drainage
in usual ,ay
$adical e"cision of neoplasms of submandibular2sublingual gland
Dxcision of fran"ly malignant invasive neoplasms of submandibular or
sublingual salivary gland ,ill include the tongue on that side, floor of the mouth and
mandible together ,ith a radical nec" dissection of palpable nodes if present
'"cision of palatal pleomorphic adenomas
Small palatal pleomorphic adenomas cause only pressure resorption of palate
and rarely invade bone The incision is deepened to bone and specimen reflected off
the hard palate ,ith the periosteum The neoplasm fre-uently sits over the greater
palatine foramen and the periosteum is freed here until the lesion can be dra,n
do,n and neurovascular bundle is clamped, sectioned and coagulated ,ith diathermy
before it is sectioned %nterrupted sil" sutures are then placed and tied together
to retain a pac" soa"ed in =hitehead0s varnish
=hen full thic"ness of the soft palate has to be removed for ade-uate
tumour clearance then the defect is repaired by an Gisland flapH described by
=orthington !1;@(#
&?
'"cision of palatal mucoepidermoid carcinoma
>o,*grade mucoepidermoid carcinomas may be treated by excision of
a full thic"ness disc of palate, including palatal and alveolar bone 'asal and oral
mucous membranes are then se,n together around the defect and stabilised ,ith a
gutta*percha obturator Surgical repair of such defects should be underta"en only
at least after + years due to the possibility of a recurrence
'"cision of palatal adenoid cystic carcinoma
Danger ,ith these neoplasms is that the surgical margin may be
inade-uate and spread can occur along perineural tissues of palatine nerves into
s"ull base .ence a combination of surgery and radiotherapy is the best
Surgical excision should include a hemimaxillectomy including orbital
floor, ,hich is the minimum =here soft palate and pterygoid region is involved,
G5roc"elt0s extended maxillectomy approachH is essential to remove ade-uate
excision under direct vision
+eoplasms of chee% and lips
Slo, gro,ing lumps can be removed ,ith a margin of normal adjacent tissue,
using scissors to effect dissection ) biopsy is mandatory if there is any doubt in
the mind of the operator 5linically aggressive neoplasms can be biopsied since
ade-uate treatment may involve radiotherapy and full thic"ness excision and repair
Strictures
Strictures can result from resolutions of the ulcerations of the duct lining
that occurred secondary to the presence of sialoliths Sometimes the ulcerations
,ill result in the discharge of stone into the mouth forming a fistula 1ut if fistula
closes a stricture ,ill result %f transverse incisions are put on the duct, strictures
can develop Those close to the papilla can be treated by papillotomy Those
posterior in the duct can be treated by implanting the divided end of the duct into
the floor of the mouth ie, sialodochoplasty, but those close to the submandibular
gland ,ill re-uire gland excision
&@
Dilation
Strictures of parotid duct can be managed by dilation ,ith probes This is
done slo,ly and the procedure may have to be repeated t,o or three times at $
,ee"s intervals, but dilation may be effective for a long period of time
!apillotomy
) fine probe is passed into the duct to mar" the lumen =ith a probe or a
thread serving as a guide a fine pointed scissors is passed into the duct and papilla
is laid open 5ut is continued posteriorly until the dilated portion of duct proximal
to the strictures is reached 4sing a +: chromic suture, cut edge of the duct lining
is se,n to the mucosa of the mouth /esultant opening remains some,hat ,ide for a
month or so, then narro,s to a acceptable degree
Sialodochoplasty
.ere the duct is completely divided and implanted into the floor of the
mouth T,o sutures are made one beneath the papilla and other behind surgical area
putting tension on the mucous membrane ) incision is made over the duct and
region of stricture is identified ) suture is placed around the duct and then a
longitudinal incision is made in the duct behind the stricture 7osterior end of the
slit is se,n to the posterior part of the ,ound edge ,ith a +: chromic suture
3urther sutures are placed so that either side of slit may be se,n to either side of
the incision in floor of the mouth Then a suture is passed do,n through the under
side of the duct just beneath the anterior end of slit, duct is then transacted to
the anterior longitudinal portion of the incision and remainder of cut end of duct is
then se,n into place more inferiorly 'onfunctional end of duct is ligated and
remainder of incision in floor of mouth in front of and behind the implantation is
closed
&9
'"$pli#ati"ns Of Salivary &land Surgery
Freys syndrome
)bout one in ten patients ,ho have parotid gland surgery suffer from
gustatory s,eating This is caused by damage to auriculotemporal nerve or to
communicating branches of facial nerve Subse-uently during repair, fibres from
otic ganglion come to supply s,eat glands 2nly rarely is this complication severe to
re-uire treatment 2nly effective treatment is to divide parasympathetic fibres
from glossopharyngeal nerve either during their intracranial course in lesser
superficial petrosal nerve or in the tympanic and hypotympanic branches of
glossopharyngeal nerve, ,here they lie behind the round ,indo, in the inner aspect
of middle ear
Facial paralysis
Symmetry of the face at rest can be restored by use of facial sling Strips
are cut from a ribbon of fascia from patient0s o,n thigh These are inserted as
loops by a techni-ue similar to that used to insert circumferential ,ires and are
tied onto the parotid fascia and temporal fascia 1oth the upper and lo,er lips are
pulled over to bring the centre point bac" into the midline
'asolabial fold is re*established and lo,er lid dra,n up into contact ,ith the
globe ) pleasant appearance is thus achieved ,hile the face is at rest and general
effect is not so unpleasant for the observer
&;
'"n#lusi"n
)lthough a ,ide variety of disorders can affect the salivary glands, most of
these are relatively uncommon in the spectrum of medical pathology
) thorough "no,ledge of the normal and abnormal physiology of the salivary
glands, and the surgical anatomy of the structures, is necessary for the successful
management of these conditions
REFERENCES
1 ) Textboo" of 2ral 7athologyF Shafer, .ine and >evyF (
th
edition 1;;&
$ 1ur"et0s 2ral MedicineF Ddited by >ynchF ;
th
edition 1;;(
& Differential Diagnosis of 2ral >esionsF =ood and EoazF &
rd
edition 1;9+
( Management of Salivary Eland >esionsF Eranic" and .annaF 1;;&
+ 6ruger0s Textboo" of 2ral and Maxillofacial SurgeryF Eustav 2 6ruger F1;;:
? 1asic 7athologyF 6umar, 5otran and /obbinsF +
th
editionF 1;;$
@ The diagnosis and surgical management of salivary gland disorders S D
3einberg %n 1asic 7rinciples of 2ral and Maxillofacial Surgery 7eterson,
Marciani, %ndresano !eds# 1;;(
9 Surgery of Mouth and Ja,s J / Moore !ed# 1;9+
(:

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