**11/04/2025** SALIVARY GLAND SURGERY Magdaleno Foo Discipline Lead Oral Maxillofacial Surgery Major and minor salivary glands * Normal function and health of the mouth depends on normal secretion of saliva by the major and minor glands * Parotid, submandibular, and sublingual glands are paired major salivary glands * Minor salivary glands are located in the lips, buccal mucosa, and linings of the mouth and throat. **Obstruction** | Salivary calculi (stone) | Duct strictures | Mucocele | | :--- | :--- | :--- |   #### Overview of Salivary Glands Normal function and health of the mouth depends on the normal secretion of saliva by both major and minor glands. - **Major Salivary Glands**: These consist of the paired parotid, submandibular, and sublingual glands. - **Minor Salivary Glands**: These are distributed throughout the lips, buccal mucosa, and the linings of the mouth and throat. #### Common Obstructive Conditions Salivary gland dysfunction often involves obstructive pathologies, including: - **Salivary calculi**: The formation of stones within the gland or duct system. - **Duct strictures**: Narrowing of the salivary ducts that impedes flow. - **Mucocele**: Mucous extravasation or retention phenomena typically affecting minor glands. Anatomical diagram of the human head and neck illustrating major salivary glands. Visible labels include 'Parotid gland', 'Stensen's (parotid) duct', 'Masseter muscle', 'Submandibular gland', 'Wharton's (submandibular) duct', 'Buccinator muscle', and 'Sublingual gland'. The image visually demonstrates the location of these paired glands relative to surrounding facial muscles. A visual chart titled 'Obstruction' that categorizes three types of salivary gland obstructions. It displays three distinct labeled boxes: 'Salivary calculi (stone)', 'Duct strictures', and 'Mucocele'. This figure serves to summarize and compare the different causes of obstruction discussed in the context. 11/04/2025 * Commonest disorder of the salivary glands * 80 % occurs in the submandibular gland * Calculi formed by deposition of calcium salts around a nidus of organic material * Calculi may cause the duct lining to undergo squamous metaplasia * Adherent layer of microbial flora grows on stones and together with obstruction, triggers inflammation and fibrosis around the duct OBSTRUCTION OF SMG * Stone in submandibular duct * CT * MRI * Sialography Sialography * Radiographic examination of the salivary glands * Injection of a small amount of contrast medium into the salivary duct of a single gland, followed by radiographs 2    #### Pathophysiology and Characteristics - Commonest disorder of the salivary glands - 80% occurs in the submandibular gland - Calculi formed by deposition of calcium salts around a nidus of organic material - Calculi may cause the duct lining to undergo squamous metaplasia - Adherent layer of microbial flora grows on stones and together with obstruction, triggers inflammation and fibrosis around the duct #### Diagnostic Imaging for Submandibular Obstruction - CT - MRI - Sialography #### Sialography Overview - Radiographic examination of the salivary glands - Injection of a small amount of contrast medium into the salivary duct of a single gland, followed by radiographs Clinical photo showing intraoral view of the floor of the mouth with a visible submandibular salivary stone (calculi) at the opening of Wharton's duct. This image demonstrates the physical presentation of sialolithiasis, a common disorder where calculi form by calcium salt deposition around organic material. Axial CT scan image demonstrating obstruction of the Submandibular Gland (SMG). The visual highlights a radiopaque stone located in the submandibular duct, which is identified as a key cause of gland obstruction and subsequent inflammation or fibrosis. Composite figure illustrating Sialography. It includes two X-ray images: one labeled 'Sialogram Parotid Gland' showing contrast filling the parotid duct system, and another showing the injection technique into the submandibular duct. These visuals demonstrate the diagnostic procedure involving contrast medium injection to visualize ductal anatomy. **11/04/2025** **Sialoendoscopy** * Wire basket retrieval of stone **Mucocoele** * Most common type is the extravasation mucocele of minor glands * Affects particularly the lower lip * Caused by damage to the duct of a minor gland and extravasation of saliva into surrounding tissue causing inflammation * Saliva pools to form a mucocoele * Small superficial mucocele should be excised with the underlying gland **3**    #### Sialoendoscopy Techniques - Wire basket retrieval of stone #### Mucocoele Characteristics - Most common type is the extravasation mucocele of minor glands - Affects particularly the lower lip - Caused by damage to the duct of a minor gland and extravasation of saliva into surrounding tissue causing inflammation - Saliva pools to form a mucocoele - Small superficial mucocele should be excised with the underlying gland Clinical photo showing a set of sialoendoscopy instruments laid out on a blue background. Visible items include various forceps, scissors, and a wire basket catheter with its handle, which corresponds to the OCR text 'Wire basket retrieval of stone'. Educational figure titled 'Sialoendoscopy'. On the left is an endoscopic view (radiograph-like image) showing a white stone inside a duct. On the right is a caption box stating 'Wire basket retrieval of stone', illustrating the procedure for removing the calculus. Clinical photo showing a close-up of the lower lip with a visible mucocele—a small, translucent fluid-filled cyst. This visual demonstrates the condition described in the adjacent text: 'Most common type is the extravasation mucocele of minor glands... Affects particularly the lower lip.' 11/04/2025 **Ranula** - Mucous extravasation cyst involving a sublingual gland and is a type of mucocele found on the floor of the mouth - Soft, fluctuant and bluish - Usually 2-3 cm in diameter and may interfere with speech or mastication - Treatment is marsupialisation with removal of sublingual gland or excision of the cyst plus the sublingual gland **Floor of mouth** SUBLINGUAL GLAND ANATOMY 4    #### Ranula Clinical Presentation - Mucous extravasation cyst involving a sublingual gland and is a type of mucocele found on the floor of the mouth - Soft, fluctuant and bluish - Usually 2-3 cm in diameter and may interfere with speech or mastication #### Management - Treatment is marsupialisation with removal of sublingual gland or excision of the cyst plus the sublingual gland #### Anatomy - Floor of mouth - Sublingual gland anatomy Clinical photograph of a patient's open mouth showing the floor of the mouth. The image displays a large, soft, fluctuant, bluish cyst (Ranula) located on the floor of the mouth. A small inset photo in the top-left corner shows a frog for visual comparison. Labeled anatomical diagram of the sublingual gland anatomy. The illustration depicts the oral cavity with teeth and tongue, highlighting the location of the sublingual gland. Callouts identify the lingual nerve and submandibular duct. Anatomical cross-section diagram of the floor of the mouth. The image illustrates the inferior alveolar nerve and artery, as well as the lingual nerve within the mandible structure. # Complications of SMG surgery * Weakness of the lower lip – *marginal mandibular branch* of the facial nerve is the nerve most likely to be bruised in the removal of a submandibular gland. * Other complications are lingual and hypoglossal nerve injuries --- # Submandibular Triangle Submandibular gland Edge of mandible Lingual n. Liypoglossal n. (Hypoglossal n.) R. Digastric m. A. Digastric m. Submandibular gland Whatson's duct **SUBMANDIBULAR GLAND ANATOMY** --- ## Management of salivary gland obstruction * Antibiotics for underlying salivary gland infections * Litholipsy +/- suloendoscopy to retrieve calculi * Extcision of calculi from Whatser's duct (subolithotomy) * Excision of the gland (submandibular gland or superficial parotidectomy)   #### Nerve Injuries - Weakness of the lower lip – marginal mandibular branch of the facial nerve is the nerve most likely to be bruised in the removal of a submandibular gland. - Other complications are lingual and hypoglossal nerve injuries #### Anatomical Structures - Submandibular gland - Edge of mandible - Lingual nerve - Hypoglossal nerve - Digastric muscle (Anterior and Posterior) - Wharton's duct #### Management of Salivary Gland Obstruction - Antibiotics for underlying salivary gland infections - Lithotripsy +/- sialoendoscopy to retrieve calculi - Excision of calculi from Wharton's duct (sialolithotomy) - Excision of the gland (submandibular gland or superficial parotidectomy) Labeled anatomical diagram of the submandibular region showing a side profile of a human head. Labels point to the 'Submandibular gland', 'Wharton's duct', 'Marginal mandibular nerve', and 'Submandibular gland'. Black and white line drawing labeled 'Submandibular Triangle'. The diagram illustrates the anatomy of the neck with callouts pointing to the 'Submandibular gland', 'Edge of mandible', 'Lingual n.', 'Hypoglossal n.', 'R. Digastric m.', and 'A. Digastric m.'. # Lymphoepithelial cysts * Slow growing unilocular or multilocular lesions, predominantly in the parotid glands * Obstruction of salivary ducts by diffuse lymphoid infiltrate * Seen in patients with HIV infection as part of diffuse infiltrative lymphocytosis syndrome * In non-HIV individuals with autoimmune disease e.g. Sjogren syndrome, lymphocytes infiltrate the gland and choose around ducts. The result is destruction of acini and replacement of the whole gland by dense lymphocytic infiltrate # BILATERAL PAROTID ENLARGEMENT # Salivary gland tumours * Global annual incidence of 0.4-13.5 cases per 100,000 * Commonly appear in sixth decade of life * Malignant lesions typically present after age 60 years * Benign lesions usually present between 40-60 years * Malignant tumours distributed equally between the sexes * Incidence of salivary gland cancers in Australia is 1.2 per 100,000 and mortality is 0.3 per 100,000 * Accounts for 5-6% of head and neck cancers, and 0.3-1% of all sites of malignancy  #### Lymphoepithelial Cysts - Slow growing unilocular or multilocular lesions, predominantly in the parotid glands - Obstruction of salivary ducts by diffuse lymphoid infiltrate - Seen in patients with HIV infection as part of diffuse infiltrative lymphocytosis syndrome - In non-HIV individuals with autoimmune disease (e.g., Sjogren syndrome), lymphocytes infiltrate the gland and choose around ducts, resulting in destruction of acini and replacement of the gland by dense lymphocytic infiltrate #### Bilateral Parotid Enlargement #### Salivary Gland Tumours Overview - Global annual incidence of 0.4-13.5 cases per 100,000 - Commonly appear in sixth decade of life - Malignant lesions typically present after age 60 years - Benign lesions usually present between 40-60 years - Malignant tumours distributed equally between the sexes - Incidence of salivary gland cancers in Australia is 1.2 per 100,000 and mortality is 0.3 per 100,000 - Accounts for 5-6% of head and neck cancers, and 0.3-1% of all sites of malignancy Clinical photograph of a patient showing bilateral parotid enlargement. The image displays significant swelling of both sides of the face, particularly in the region of the parotid glands, consistent with the text description of 'BILATERAL PAROTID ENLARGEMENT'. 11/04/2025 # Salivary gland tumours **Parotid:** 70-85% of all tumors & 25-32% are malignant **Minor Glands:** 22% of all tumors & 45-82% are malignant **Sublingual:** <1-5% of all tumors & 70-90% are malignant **Submandibular Glands:** 8% of all tumors & 37-45% are malignant --- # Salivary gland neoplasms ### Epithelial tumours #### Adenomas * Pleomorphic adenoma * Warthin's tumour * Oncocytoma * Basal cell adenoma --- # Salivary gland neoplasms ### Epithelial tumours #### Carcinomas * Mucoepidermoid carcinoma * Acinic cell carcinoma * Adenoid cystic carcinoma * Polymorphous low-grade adenocarcinoma * Salivary duct carcinoma * Epithelial-myoepithelial carcinoma * Adenocarcinoma * Undifferentiated carcinoma * Carcinoma ex pleomorphic adenoma 7    #### Tumor Distribution by Gland Site - **Parotid:** 70-85% of all tumors; 25-32% are malignant - **Minor Glands:** 22% of all tumors; 45-82% are malignant - **Sublingual:** <1-5% of all tumors; 70-90% are malignant - **Submandibular Glands:** 8% of all tumors; 37-45% are malignant #### Adenomas - Pleomorphic adenoma - Warthin's tumour - Oncocytoma - Basal cell adenoma #### Carcinomas - Mucoepidermoid carcinoma - Acinic cell carcinoma - Adenoid cystic carcinoma - Polymorphous low-grade adenocarcinoma - Salivary duct carcinoma - Epithelial-myoepithelial carcinoma - Adenocarcinoma - Undifferentiated carcinoma - Carcinoma ex pleomorphic adenoma Anatomical diagram of the head and neck region showing the location of salivary glands. The image includes a labeled overlay indicating 'Parotid', 'Minor Glands', 'Sublingual', and 'Submandibular' glands with associated statistics on tumor prevalence and malignancy rates (e.g., Parotid: 70-85% of all tumors & 25-32% are malignant). A text box titled 'Salivary gland tumours' is positioned to the right of the anatomical illustration. Hierarchical chart titled 'Salivary gland neoplasms'. It organizes information into categories using blue header bars. The first level shows 'Epithelial tumours'. The second level breaks this down into 'Adenomas', followed by a list of specific types: Pleomorphic adenoma, Warthin's tumour, Oncocytoma, and Basal cell adenoma. Hierarchical chart titled 'Salivary gland neoplasms'. It organizes information into categories using blue header bars. The first level shows 'Epithelial tumours'. The second level breaks this down into 'Carcinomas', followed by a comprehensive list of specific types including Mucoepidermoid carcinoma, Acinic cell carcinoma, Adenoid cystic carcinoma, Polymorphous low-grade adenocarcinoma, Salivary duct carcinoma, Epithelial-myoepithelial carcinoma, Adenocarcinoma, Undifferentiated carcinoma, and Carcinoma ex pleomorphic adenoma. 11/04/2025 Salivary gland neoplasms Non-epithelial tumours • Lymphomas • Metastases to parotid lymph nodes and submandibular lymph nodes LYMPH NODES Metastases to lymph nodes Clinical features of salivary gland tumours | Benign salivary gland tumours | Malignant salivary gland tumours | | :--- | :--- | | • Slow-growing | • Sometimes fast-growing and painful | | • Soft consistency | • Sometimes hard consistency | | • 85% of parotid tumours | • Comprise 45% of minor gland tumours | | • Do not ulcerate | • May ulcerate and invade bone | | • No associated nerve signs | • May cause cranial nerve palsies | 8    #### Types and Lymph Node Involvement - Lymphomas - Metastases to parotid lymph nodes and submandibular lymph nodes #### Comparison of Benign vs. Malignant Tumours | Benign salivary gland tumours | Malignant salivary gland tumours | | :--- | :--- | | • Slow-growing | • Sometimes fast-growing and painful | | • Soft consistency | • Sometimes hard consistency | | • 85% of parotid tumours | • Comprise 45% of minor gland tumours | | • Do not ulcerate | • May ulcerate and invade bone | | • No associated nerve signs | • May cause cranial nerve palsies | Text-based slide titled 'Salivary gland neoplasms' with a green highlight box for 'Non-epithelial tumours', listing 'Lymphomas' and 'Metastases to parotid lymph nodes and submandibular lymph nodes'. This is a text-only region without visual structures like diagrams or charts. Anatomical diagram of human head and neck showing lymph node locations. Labels include 'Parotid lymph nodes', 'Submental lymph nodes', 'Submandibular lymph nodes', 'Superior deep cervical lymph nodes', 'Inferior deep cervical lymph nodes', and 'Anterior jugular lymph nodes'. Text overlay reads 'LYMPH NODES' and 'Metastases to lymph nodes'. Comparison table titled 'Clinical features of salivary gland tumours' with two columns: 'Benign salivary gland tumours' (slow-growing, soft consistency, 85% of parotid tumours, do not ulcerate, no associated nerve signs) and 'Malignant salivary gland tumours' (sometimes fast-growing and painful, sometimes hard consistency, comprise 45% of minor gland tumours, may ulcerate and invade bone, may cause cranial nerve palsies). **11/04/2025** Malignant parotid tumour * Hard fixed lump * Numbness * Muscle weakness * Difficulty swallowing * Trismus * Lymph node metastasis Diagnostic imaging * Salography useful for inflammatory disease * CT, US and MRI for suspected neoplasm * MRI often superior to CT in demonstrating interface of tumour and surrounding tissue to predict possible malignancy Fine needle aspiration cytology (FNAC) * Evaluation of head and neck tumours * Provides distinction between benign and malignant tumours * Inexpensive, easy to perform, relatively painless and well tolerated * Correctly establishing diagnosis as benign or malignant in 81.98% of cases * False positive and false negative rates 1-14% * Specific diagnosis in 60-75% * Accuracy of FNAC varies depending on the precision and experience of the pathologist 9  #### Malignant Parotid Tumour Symptoms - Hard fixed lump - Numbness - Muscle weakness - Difficulty swallowing - Trismus - Lymph node metastasis #### Diagnostic Imaging - Sialography: useful for inflammatory disease - CT, US, and MRI: for suspected neoplasm - MRI: often superior to CT in demonstrating interface of tumour and surrounding tissue to predict possible malignancy #### Fine Needle Aspiration Cytology (FNAC) - Evaluation of head and neck tumours - Provides distinction between benign and malignant tumours - Inexpensive, easy to perform, relatively painless, and well tolerated - Correctly establishing diagnosis as benign or malignant in 81.98% of cases - False positive and false negative rates: 1-14% - Specific diagnosis in 60-75% - Accuracy varies depending on the precision and experience of the pathologist Clinical photograph showing a patient with a malignant parotid tumour. The image displays significant facial asymmetry and swelling on one side of the face, consistent with a hard fixed lump in the parotid region as described in the adjacent text. **11/04/2025** **PAROTID TUMOUR** **FACIAL NERVE** **10**   #### Parotid Tumour and Facial Nerve Anatomy Clinical composite image showing a procedure (left) and ultrasound scan (right). The left panel depicts a medical professional performing an intervention on a patient's head/neck region using instruments. The right panel displays a grayscale ultrasound image with a white arrowhead indicating a specific anatomical finding or lesion. A caption below reads: 'CORRELATION OF CYTOLOGICAL DIAGNOSIS AND IMAGING STUDIES GUIDE DIFFERENT TREATMENT PATHWAY'. Medical documentation slide titled 'PAROTID TUMOUR'. It features a clinical photograph of a patient's lateral face showing a visible mass in the parotid region adjacent to the ear, alongside a document placeholder labeled 'PAROTID TUMOUR'. **11/04/2025** **Parotid gland malignancy** * Parotid gland malignancies with clinically evident regional nodal metastasis should undergo a formal neck dissection, followed by appropriate adjuvant therapy e.g. radiotherapy **Radiotherapy**  #### Management of Parotid Gland Malignancy - Parotid gland malignancies with clinically evident regional nodal metastasis should undergo a formal neck dissection, followed by appropriate adjuvant therapy (e.g., radiotherapy). #### Adjuvant Therapy - Radiotherapy Clinical photograph showing the results of a neck dissection for parotid malignancy. The image displays two views: on the left, an intraoperative view of the exposed surgical field in the neck with visible tissue and blood; on the right, the gross pathology specimen (likely lymph nodes or tumor mass) removed during the procedure, presented against a blue background. 11/04/2025 Hole in palate Obturador 12    #### Palatal Defects - Hole in palate - Obturator Clinical photo of a minor salivary gland tumour. The image shows an intraoral view with a visible swelling on the buccal mucosa or gingiva. Clinical photo of a hole in palate. The image shows a defect in the hard palate with surrounding tissue and teeth visible. Clinical photo of an obturator. The image shows a dental appliance used to close a gap in the palate, fitting over the upper teeth. 11/04/2025 13  Clinical photo showing a graft applied to a palatal defect. The image displays the inside of a mouth with a pinkish tissue graft covering an area on the roof of the mouth (palate). A gloved hand is visible holding the patient's cheek or lip aside to provide a clear view of the surgical site. The caption 'Graft to palatal defect' is present above the image. [^1]: Original PDF page 1: [[W3.1 Salivary gland surgery.pdf#page=1|W3.1 Salivary gland surgery, p.1]] [^2]: Original PDF page 2: [[W3.1 Salivary gland surgery.pdf#page=2|W3.1 Salivary gland surgery, p.2]] [^3]: Original PDF page 3: [[W3.1 Salivary gland surgery.pdf#page=3|W3.1 Salivary gland surgery, p.3]] [^4]: Original PDF page 4: [[W3.1 Salivary gland surgery.pdf#page=4|W3.1 Salivary gland surgery, p.4]] [^5]: Original PDF page 5: [[W3.1 Salivary gland surgery.pdf#page=5|W3.1 Salivary gland surgery, p.5]] [^6]: Original PDF page 6: [[W3.1 Salivary gland surgery.pdf#page=6|W3.1 Salivary gland surgery, p.6]] [^7]: Original PDF page 7: [[W3.1 Salivary gland surgery.pdf#page=7|W3.1 Salivary gland surgery, p.7]] [^8]: Original PDF page 8: [[W3.1 Salivary gland surgery.pdf#page=8|W3.1 Salivary gland surgery, p.8]] [^9]: Original PDF page 9: [[W3.1 Salivary gland surgery.pdf#page=9|W3.1 Salivary gland surgery, p.9]] [^10]: Original PDF page 10: [[W3.1 Salivary gland surgery.pdf#page=10|W3.1 Salivary gland surgery, p.10]] [^11]: Original PDF page 11: [[W3.1 Salivary gland surgery.pdf#page=11|W3.1 Salivary gland surgery, p.11]] [^12]: Original PDF page 12: [[W3.1 Salivary gland surgery.pdf#page=12|W3.1 Salivary gland surgery, p.12]] [^13]: Original PDF page 13: [[W3.1 Salivary gland surgery.pdf#page=13|W3.1 Salivary gland surgery, p.13]]