ENT [SALIVARY GLAND DISEASES]

Dra. Almazan
Learning Objectives Functions:
o Facilitates swallowing
1. Anatomy of Salivary gland o Keeps the mouth moist and aids speech
2. Diagnostic Approach to Salivary Gland diseases o Serves as a solvent for molecules which stimulate the
3. Salivary Diseases taste buds
o Cleans the mouth, gums and teeth
a. Inflammatory diseases
o Contains enzymes
b. Salivary Gland Stones (Sialolithiasis)
c. Salivary Gland Tumors DIAGNOSTIC APPROACHES
d. Autoimmune Diseases Primary approaches:
e. Salivary Diseases in Children 1. Evaluation of dry mouth
2. Past and Present Medical History
ANATOMY 3. Clinical Examination
o 2 Submandibular Adjuncts:
o 2 Parotid 4. Saliva Collection
o 2 Sublingual 5. Salivary Gland Imaging
o >400 minor salivary glands 6. Salivary Gland biopsy and FNA
7. Serologic Evaluation
A. SUBMANDIBULAR GLAND (Submaxillary)
WHARTONs DUCT (lateral to the Lingual Frenulum) 1. Clinical History
The gland forms a C around the anterior margin of the History of swellings/ change over time
MYLOHYOID muscle; a superficial and deep lobe. Trismus
Pain
B. PAROTID GLAND Variation with meals
LARGEST salivary gland Bilateral
FACIAL nerve divides it into 2 surgical zone(Superficial and Dry mouth? Dry eyes
Deep Lobes) Recent exposure to sick contacts (mumps)
STENSENs duct Radiation history
o 1.5cm inferior to the zygomatic arch Current medications
o Superficial to the masseter muscle
o Turns medially, 90 degrees to pierce the buccinator muscle 2. Clinical Examination
nd
o At the level of the 2 maxillary molar where it opens into Extra-Oral Examination
the oral cavity o Palpate cervical lymph nodes
Followed by 5 Terminal branches o Palpate the glands (slightly rubbery, painless
1. Temporal unless infected/ inflammed)
2. Zygomatic o Check motor function of facial nerve
3. Buccal 3. Others
4. Marginal Mandibular Plain Film Radiography
5. Cervical Sialography
Ultrasongraphy
C. SUBLINGUAL GLAND Radionuclide imaging
SMALLEST of the major salivary glands Computed Tomography (CT)
Almond shape Magnetic Resonance Imaging (MRI)
Deep to the floor of mouth mucosa
It is drained approximately by 10 small ducts (Ducts of Rivinu) SPECIFIC DISEASES AND DISORDERS

D. MINOR SALIVARY Glands Developmental Abnormalities

These just lie under the mucosa Mucoceles & Ranula
Distributed over lips, cheeks, hard palate, floor of the mouth Inflammatory & Reactive Lesions
and retromolar area Sialolithiasis
Also appear in upper aerodigestive tract Immune conditions
Contribute 10% of total salivary volume Granulomatous conditions
Salivary Gland tumors

PHYSIOLOGY
1500ml of saliva per day
From the Parotid Gland: thin, watery fluid
From Submandibular and Sublingual Glands: thicker

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 ENT [SALIVARY GLAND DISEASES]
Dra. Almazan
I. DEVELOPMENTAL ABNORMALITIES o Viral serology: Antibiotics
1. Absence of Salivary Gland Treatment:
Rare o Supportive
Associated with other developmental defects o Promote fluid intake
2. Accessory salivary duct o Anti-inflammatory and analgesics
3. Diverticuli Complications:
Pouch in the duct wall o 20 % Orchitis
-testicular atrophy and sterility in young men
II. SIALADENITIS o 10% Meningitis
o 15% Oophoritis
1. Bacterial Sialadenitis o 5% Pancreatitis
Can be: Acute, chronic, recurrent Parotitis o <5% Hearing loss
Parotid Gland is most commonly affected -usually permanent and 80% unilateral
Susceptible individuals:
o With gland hypofunction 3. Allergic Sialadenitits
o age extremes (infants, elderly) Caused by drugs or allergens
o those with poor oral hygiene Clinical Presentation:
Clinical picture: o Acute salivary gland enlargement
o Sudden onset o Itching over the gland
o Gland is painful o With/ without rash
o Indurated Treatment:
o Erythematous overlying skin o Self-limited disease
o Raises the lobule of the ear o Supportive therapy
o Temperature: above 37.8C o Avoid allergen
Acute Supurative Sialadenitis o Hydration
o Ascending infection 4. Post-irradiation
o S.aureus, S.viridans 5. Sarcoidosis
o From the oral cavity 6. Sialadenitis of minor glands
o By a reduction in salivary flow
o Following major surgical operation
Due to dehydration III. SIALOLITHIASIS
Poor oral hygiene One or more round of oval calcified structures in the duct of
Diagnostic Exam: the major or minor salivary glands
o Parotitis is a clinical diagnosis SALIVARY CALCULI
o Elevated WBC most common: Submandibular gland
o Adjuncts: MRI, CTscan or Ultrasound pain subsides before swelling
o Needle aspiration of abcess recurrent painful swelling at mealtime
o Pus expressed from the duct for C&S acute & subacute infection
Treatment: persistent obstruction damages the gland and making it harder
o IV Antibiotic and tender
o Milk the gland several times a day Presentation:
o Increase hydration o Skin is red, edematous
o Improve oral hygiene o Hot & tender if infected
o Do, bimanual palpation
2. Acute Viral Infection Sialography
Mumps Parotitis caused by Paramyxovirus o Demonstrate the lumen of the ducts for stone, tumor or
Broad range of viral pathogens stricture
SYSTEMIC from onset Treatment:
Can also be Cytomegalovirus o Conservative
Physical Examination: Antibiotics
o Headache, mylagia, anorexia, malaise, fever Anti-inflammatory
o Glandular swelling (tense, firm) o Excision
o Earache, gland pain, dysphagia and trismus Lithotripsy
o May displace pinna ipsilaterally Sialoendoscopy
o 75% cases involve bilateral parotids If manipulation fails then a surgical cut is made
Diagnostic Evaluation: into the duct
o Leukocytopenia + Relative Lymphocytosis Gland excision (if the stone is within the gland
o Increased serum amylase and if the gland is severely damaged

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 ENT [SALIVARY GLAND DISEASES]
Dra. Almazan
Diagnostics:
IV. GRANULOMATOUS CONDITIONS o CT/ MRI
1. Tuberculosis o FNAC
Xerostomia o No Open biopsy
Salivary Gland enlargement Management:
2. Sarcoidosis o Intracapsular Excision: Small & encased within the
Severity and duration of the disease varies capsule
Mild improvement noticed with steroid therapy o Excision: large & benign
o Concomitant Neck Dissection: malignant tumors
V. SJOGREN SYNDROME
Autoimmune condition causing progressive degeneration 4. PAROTID TUMORS
of salivary and lacrimal glands Most common is Pleomorphic Adenoma (80-90%)
Connective tissue disorder such as rheumatoid arthritis Low grade tumors are not distinguishable from benign tumors
Clinical Presentation: High grade tumors grow rapidly, often painful and have lymph
o Mostly affects the parotid gland node metastasis
o Persistent/ intermittent gland enlargement CT/ MRI are useful
o Bilateral, non-tender, firm and diffuse swelling FNAC better than open biopsy
o Decrease saliva and altered saliva composition, Treatment: EXCISION
xerostomia
o Significantly increased risk of developing B-cell **Pleomorphic Adenoma
Lymphoma o Benign
o Keratoconjunctivitis sicca o Most common salivary tumor
Diagnosis: o In middle aged, Women
o Biopsy of salivary gland: lower lip o Slowly growing
Treatment: o Treatment: Superficial Parotidectomy
o Treat recurrent infection
o Salivary substitutes/ sprays Classification of Parotid Tumors
o Cholinergic drugs (Pilocarpine)
o Avoid alcohol, tobacco Adenoma Carcinoma
o Immunosuppressive drugs, corticosteroids, cytotoxic o Pleomorphic o Low Grade (Acinic Cell/
agents o Monomorphic (Warthins Adenoid cystic)
Tumor) o High Grade
VI. SALIVARY GLAND TUMORS (Adenocarcinoma/
Squamous Cell
Frequency (%) Malignant (%) Carcinoma)
Parotid Glands 65 25
Submandibular Glands 10 40 Management:
Sublingual Glands <1 90 Superficial Parotidectomy
Minor Salivary Glands 25 50 -most common procedure
Radical Parotidectomy
1. DISORDERS OF MINOR SALIVARY GLANDS -is performed for patients with clear histological
Malignant evidence of high grade malignancy
Extravasation Cysts Surgery: Parotidectomy
o Follows after trauma -Superficial
o Mainly MSG lower lip -Total
o Visible painful swelling
o Some resolve spontaneously, others require surgery 5. CARCINOMA
Hard, rapidly growing infiltrating mass with fixation
2. DISORDERS OF SUBLINGUL GLANDS Resorption of bone & ulcer
Are very RARE Presentation:
Minor mucous retention cysts o Pain
Plunging ranula is a retention cyst that tunnels deep o Muscle spasm
Nearly all tumors are malignant o Later, paralysis
Diagnosis:
3. TUMORS OF SUBMANDIBULAR GLANDS o FNA cytology
Uncommon o CT scan
Slowly growing, painless
10% malignant
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 ENT [SALIVARY GLAND DISEASES]
Dra. Almazan
Treatment:
o Radical excision
o Lymph node dissection
o Radiotherapy

Intraoperative Postoperative Complications

Complications Early Late
Transection of Facial nerve paralysis Facial sinkinesis after
Facial Nerve facial palsy
Rupture of o Hemorrhage Hypoesthesia of greater
capsulae of Parotid o Hematoma auricular nerve
tumor
Incomplete o Infection o Recurrent tumor
surgical resection o Skin flap necrosis o Soft tissue deficit
of Parotid Tumor o Cosmetic o Hypertrophic scar
deformity or keloid
o Trismus o Freys Syndrome
o Parotid fistula

VII. DISORDERS OF MINOR SALIVARY GLANDS

MSG tumors are RARE but 90% is MALIGNANT!
Common sites:
o Upper lip
o Palate
o Retromolar regions
Rare sites:
o Nose
o PNS
o Pharynx

VIII. PLUNGING RANULA

RARE form of retention cyst
May arise from SM/ SL SG
Mucous collects around gland
Penetrates Mylohyoid muscle
Soft painless fluctuant dumb-bell shaped swelling
Surgical excision via NECK

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