ANTONIO G. TALAPIAN, M.D.

, FPSO HNS
Dept. ORL - HNS
Quezon City General Hospital
Major Salivary Glands
1. Parotid
2. Submandibular
3. Sublingual
Minor Salivary Glands
-located in the mucosa and submucosally in the
palate, tongue and oral vestibule
-form minimal amount of saliva
Saliva
- 1 to 1.5 liter produced by the major
salivary glands in 24 hrs in resting state.
- Parotid 1/3, submandibular 2/3
- Stimulus
presence of food in the mouth, esp. containing
acid.
- Direct relationship between hydration and
overall supply of saliva.
Salivary Composition
- 99.5% water
- Solids: bicarbonate and phosphate, NA, KCI,
SO4, CaCO3, Amino Acids

Salivary Calculi formed by precipitation of Ca

and Phosphate salts
Salivary Composition
- Lysozymes & IgA antibodies in mucoid saliva
(therefore, parotid has lower bacteriostatic
activity)
- Sialic acid which agglutinates bacteria and
prevents its adherence to host tissue.
- Specific glycoproteins in mucins bind epithelial
cells competitively inhibiting bacterial
attachment to these cells.
 Parotid
-Serous
Submandibular
-Serous & mucous glandular elements
Sublingual
-mucous

- Salivary response to stimulation is a

PARASYMPATHETIC nervous system response
INFLAMMATORY DISORDERS
1. Acute Parotitis
a. Mumps (Viral)
b. Acute recurrent parotitis
c. Acute suppurative parotitis (bacterial)
2. Acute Submandibular Sialadenitis
3. Chronic Sialadenitis
a. Obstructive
b. Non-obstructive
I. ACUTE PAROTITIS
a.Mumps (Viral)
most common form
(+) hx of viral exposure
low WBC, relative lymphocytosis
elevated serum amylase
Viral infection
Mumps is a non-suppurative acute sialadenitis
Endemic in the community and spread by
airborne droplets
Communicable disease
Enters through upper respiratory tract
IP: 2-3 week incubation after exposure
Viremia: 3-5 days
Clinical presentation
30% experience prodromal symptoms prior to
development of parotitis
Headache, myalgias, anorexia, malaise
Onset of salivary gland involvement is heralded
by earache, gland pain, dysphagia and trismus
Physical exam
Glandular swelling (tense, firm)
Parotid gland involved frequently, SMG & SLG can also
be affected.
May displace ispilateral pinna
75% cases involve bilateral parotids, 25% unilateral
Low grade fever
Diagnostic Evaluation
Leukocytopenia, with relative lymphocytosis
Increased serum amylase (normal by 2- 3 week of
disease)
Viral serology essential to confirm Complement fixing
antibodies appear following exposure to the virus
Treatment
Supportive
Fluids
Anti-inflammatories and analgesics
Complications
Orchitis, testicular atrophy and sterility (~20% of
young men)
Oophoritis in 5% females
Aseptic meningitis in 10%
Pancreatitis in 5%
Sensorineural hearing loss <5%
Usually permanent
80% cases are unilateral
Prevention
The live attenuated vaccine became available in 1967
COMBINED MMR
Administered in a single subcutaneous dose after 12
months of age.
Booster at 4-6 yr
b. Acute recurrent parotitis
- Parotid swelling in children, age 1 month
through late childhood
- Involves one or both glands, with pus
expressed from Stensens duct
- pneumococci
- Sialography dilatation of peripheral
ducts
ACUTE PAROTITIS
C. Acute Suppurative Parotitis (Bacterial)
- sudden onset of pain, redness and swelling of
parotid region
- pus at ductal orifice
- may occur post-op
- usually seen in debilitated or elderly persons
- poor hygiene may be associated
- Coagulase (+) Staph aureus
Acute Suppurative Parotitis
More common in parotid gland.
The etiologic factor most associated with this
entity is the retrograde infection from the mouth.
20% cases are bilateral
Acute Suppurative parotitis
Tx : IV antibiotics
: Culture & Sensitivity test
: I & D if unresponsive to medical treatment
: improved oral hygiene
: adequate hydration
: massage
Acute Submandibular Sialadenitis
- less common
- dental evaluation; possible obstruction
- Mx : C/S of pus from Whartons
: Antibiotics
: Warm compress
: removal of calculus if present
Chronic Sialadenitis
a. Chronic obstructive sialodochiectasis
associated with
-recurrent calculi
-mucus plug
-stricture
Obstructive Salivary Gland Disorders
Sialolithiasis
Mucous retention/extravasation
Sialolithiasis
Results in a mechanical obstruction of the
salivary duct
Is the major cause of unilateral diffuse
parotid or submandibular gland swelling

Acute ductal obstruction may occur at meal time when

saliva production is at its maximum; the resultant
swelling is sudden and can be painful
Reasons sialolithiasis may occur more often in the SMG:
Saliva more alkaline
Higher concentration of calcium and phosphate in the
saliva
Higher mucus content
Longer duct
Anti-gravity flow
Stone Composition
Organic; often predominate in the center
Glycoproteins
Mucopolysaccarides
Bacteria
Cellular debris
Inorganic; often in the periphery
Calcium carbonates & calcium phosphates
in the form of hydroxyapatite
Clinical presentation
Painful swelling (60%)
Painless swelling (30%)
Pain only (12%)
Sometimes described as recurrent salivary colic
and spasmodic pains upon eating
Diagnostics
Plain occlusal film
Effective for intraductal stones
Disadvantage: Intraglandular, radiolucent or
small stones may be missed
CT Scan:
large stones, small CT slices done
--also used for inflammatory disorders
Ultrasound:
operator dependent, can detect small stones (>2mm),
inexpensive, non-invasive
Sialogram:
demonstrates main duct and the finer divisions of the
duct showing a tree like appearance
Contraindication:
acute infection
Disadvantages:
Irradiation dose
Pain with procedure
Possible perforation
Infection dye reaction
Push stone further
Contraindicated in active infection
Diagnostic Sialendoscopy
Allows complete exploration of the ductal
system, direct visualization of duct pathology
Success rate of >95%2
Disadvantage: technically challenging,
trauma could result in stenosis, perforation
Sialolithiasis Treatment
None: antibiotics, C/S & antiinflammatories,
hoping for spontaneous stone passage.
Stone removal:
Lithotripsy
Interventional sialendoscopy
Simple removal (20% recurrence)
Gland excision
Stone Extraction
External lithotripsy
Stones are fragmented and expected to pass
spontaneously
The remaining stone may be the ideal nidus
for recurrence
Interventional Sialendoscopy
Can retrieve stones, may also use laser to
fragment stones and retrieve.
Gland excision
Indicated in:
Very posterior stones
Intra-glandular stones
Significantly symptomatic patients
Failed transoral approach
 Patients that defer treatment
Stones will likely enlarge over time
Seek treatment early if infection develops
Salivary gland massage and hyperhydration
when symptoms develop.
Mucocele
Mucoceles are most common of the benign soft tissue
masses in the oral cavity.
Muco: mucus , coele: cavity

When in the oral floor, they are called ranula.

Ranula
Derived form the word rana, because the swelling
may resemble the translucent underbelly of the
frog.
Source is usually the sublingual gland
Ranula Treatment
Marsupialization has fallen into disfavor due to the
excessive recurrence rate of 60-90%
Sublingual gland removal via intra-oral approach
treatment of choice
 SYSTEMIC DISEASES
1. Sarcoidosis

2. Benign lymphoepithelial disease

a. Mikuliczs disease
b. Sjgrens syndrome
1. Sarcoidosis (Heerfordts syndrome or uveo-parotid
fever)
- diffusely swollen gland with slight tenderness
- facial nerve paralysis can occur
- possible co-existence of uveitis
- Systemic manifestation:
--hypercalcemia
--enlarged liver & spleen
--enlarged cervical & hilar nodes
- Dx: biopsy
- Tx: systemic steroids
Benign lymphoepithelial disease
Sjgrens Syndrome
- Most common immunologic disorder
associated with salivary gland disease.
- diffusely enlarged salivary gland
- with concomitant disturbance of dryness
--keratoconjunctivitis sicca
--xerostomia (dryness of upper resp. and
oropharyngeal mucosa), &
- associated collagen disorder (usually
rheumatoid arthritis)
 Unilateral or bilateral salivary gland swelling occurs
May be permanent or intermittent.
90% in women
Average onset is 50 y.o.
Pathopysiology
Lymphocyte mediated destruction of the exocrine
glands leading to xerostomia and keratoconjunctivitis
sicca
BENIGN TUMORS of SG
Children:
Parotid gland more frequently involved than
Submandibular & Sublingual gland
1. Parotid Gland Hemangioma (M.C.)
skin with bluish discoloration
gradual increase in size during the first 4-6 months
evidence of resolution by age 2
Parotid Gland Hemangioma
BENIGN TUMORS of SG
2. Lymphangioma
3. Benign mixed tumor (pleomorphic adenoma)
4. Others: Neurofibroma, Lipoma
BENIGN TUMORS of SG
Adults:
1. Benign Mixed tumor (Pleomorphic Adenoma) 75%
2. Papillary cystadenoma lymphomatosum (Whartins
tumor) 26%
3. Others : oxyphil adenoma
: serous cell adenoma
Pleomorphic Adenoma

- benign mixed tumor

- 75% of all parotid tumors
- slow growing, painless swelling
- women commonly affected
- high recurrence rate
Dx. Fine Needle Aspiration Biopsy (FNAB)
Tx: superficial parotidectomy with
facial nerve preservation
Pleomorphic adenoma 2 year
history
Pleomorphic adenoma palate
Papillary cystadenoma
lymphomatosum
- (Whartins tumor)
- 50 to 60 y.o. males
- affects the tail of the parotid gland
- may be bilateral
- has well defined capsule
- Tx: Superficial parotidectomy with facial nerve
preservation
- Px: Encapsulated & less likely to recur
TUMORS OF THE
PARAPHARYNGEAL SPACE
- Commonly, salivary gland tumors arising from
deep lobe of parotid gland extending into the
parapharyngeal space
PARAPHARYNGEAL SPACE
Parapharyngeal Space Tumor
Tx: excision via extra-oral approach
MALIGNANT TUMORS
Parotid, 25%
Submandibular, 50%
Minor salivary gland, 50-60%
Malignancy considered
1. presence of increasing pain
2. facial nerve paralysis
3. rapid growth
4. skin involvement & fixation
5. presence of lymph nodes
Increasing incidence of malignancy with advancing age
Incidence:
1. Mucoepidermoid 27%
2. Adeno carcinoma 24%
3. Acinic cell 15%
4. Adenoid cystic 12%
Intermediate & Low grade
1. low-grade mucoepidermoid CA
2. acinic cell CA
3. malignant mixed tumor
Mx:
-Total parotidectomy with facial nerve
preservation
-Submandibular Gland: total resection
-Radical Neck Dissection (RND)
- recurrent malignant tumors &/or palpable nodes
High-grade Malignancy
1. High-grade mucoepidermoid
2. Squamous Cell CA
3. Undifferentiated Adeno CA
4. Adenoid Cystic CA
Mx: - Total parotidectomy with facial nerve
sacrifice, with possible RND
- Adjacent structures may be included.
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