SALIVARY

GLAND
DISORDERS
 CONTENT

 INTRODUCTION
 ANATOMY
• PAROTID GLAND
• SUBMANDIBULAR GLAND
• SUBLINGUAL GLAND
• MINOR SALIVARY GLANDS
 SALIVA
 CLASSIFICATION OF DISORDERS
 DISORDERS
• Developmental Disorders
• Inflammatory - infectious
conditions
• Obstructive Disorders
• Viral Infections of Salivary
Glands
• Functional Disorders
• Autoimmune
• Neoplastic
 SIALOGRAPHY
 REFERENCES
 INTRODUCTION

 The salivary glands are exocrine glands that discharge saliva via a duct into the oral
cavity.

 Divided into three major pairs of glands, including the parotid, submandibular and
sublingual glands, and over 400 to 1000 minor glands, including those in the tongue,
palatine tonsils, palate, lips and cheek.

 The salivary glands secrete saliva which has lubricating,

immunologic, digestive, and cleansing functions.

 They are affected by systemic and local inflammatory conditions,

obstructive pathologies, as well as neoplasms.

 The disorders that involve these glands can either be acute or

chronic inflammatory lesions, congenital abnormalities, systemic
disorders, or benign and malignant tumors.
PAROTID GLAND

• The parotid (para = around, otic =

ear) gland is the largest of the three
pairs of salivary glands.

• The parotid gland is found inferior

to the zygomatic arch and directly
anteroinferior to the external
auditory canal and
temporomandibular joint.

• To palpate the gland clinically, the

patient is required to clench the jaw
and the physician passes a finger
intraorally and in a posteromedial
direction, in the area of the
vestibule. The masseter can be felt
in its tonic state and the parotid
gland rolled on top of it by moving
the examining finger back and
forth.
 Capsule of Parotid Gland
• The investing layer of the
deep cervical fascia forms a
capsule for the gland.

• It is supplied by great
auricular nerve.

• The superficial lamina/

parotidomasseteric fascia,
thick and adherent to the
gland, is attached above to
the zygomatic arch.

• The deep lamina is thin and is

attached to the styloid
process, tympanic plate, the
angle and posterior border of
• A portion of the deep lamina, extending between the styloid
the ramus of the mandible.
process and the mandible, is thickened to form the
stylomandibular ligament which separates the parotid gland
from the submandibular salivary gland.
Parotid Duct
(Stenson’s Duct)

• Parotid duct or the Stensen’s duct

crosses the masseter about a
finger breadth below the
zygomatic arch.

• It then takes a sharp turn medially

at the anterior border of the
masseter further traversing
through the buccal fat pad and
buccinator muscle.

• It then runs obliquely between the

buccinator and oral mucosa to
open on the parotid papilla,
opposite the second maxillary
molar.
SUBMANDIBULAR SALIVARY GLAND

• It is situated in the anterior part

of the digastric triangle. The
gland is about the size of a
walnut weighing about 15 to 20
g.

• It is roughly J-shaped or hook

shaped.

• It lies beneath the lower border of

the body of the mandible

• Gland is divided into superficial and deep

parts by the mylohyoid muscle.

• The deep part of the gland lies beneath

the mucous membrane of the mouth on
the side of the tongue.
 SUBMANDIBULAR DUCT/WHARTON'S
DUCT

• The submandibular duct is

about 5 cm long and emerges at
the anterior end of the deep
part.

• This duct is longer and has a

tortous, uphill course. Thus the
secretions have to be emptied
against gravity, and there are
increased chances of retention.

It opens on the floor of the mouth, on

the summit of the sublingual papilla, at
the side of the frenulum of the tongue.
SUBLINGUAL SALIVARY GLAND

• This is smallest of the three pairs of large salivary glands.

• It lies in the floor of the mouth between the mucus membrane and the
mylohyoid muscle.

• It is almond shaped and rests in the sublingual fossa of the mandible.

• It is separated from the
base of the tongue by
the submandibular duct.

• It is mostly mucus in
nature and weighs
about 3–4 g.

• The gland pours its

secretion by a series of
ducts, about 15 in
number, into the oral
cavity on the sublingual
fold, but a few of them
open into the
Minor salivary glands

• More than 700–1,000 minor

salivary glands may be present
in the oral cavity.

• Most of them are found at the

junction of hard and soft palate.
Rest are found in the oral cavity
mucosa—lips,cheeks, floor of the
mouth, retromolar area.

• The minor glands secrete

“mucous” secretions, with the
exception of Ebner’s glands,
which are serous glands located
in the circumvallate papillae of
the tongue.

• These glands have numerous

small ducts.
 SALIVA

• Normal daily production is

around 1–1.5 liters. (1 cc/min)

• Saliva is produced at a low

basal rate throughout the day,
with flow increasing 10-folds
during meals.

• 45% is produced by parotid

glands, 45% by
submandibular glands and 5%
each by sublingual and minor
salivary glands.
 Neoplastic
• Benign
Autoimmun • Malignant
Developmen
e
• Sjogrens tal
• Aplasia,
syndrome
• Atresia,
• Mikulicz’s
• Aberrancy
disease

Traumatic/ Inflammator
Salivary y
Obstructive
• Mucocele, gland conditions
• Ranula disorders • Acute and
• Sialolithiasi chronic
s bacterial
sialadenitis
Viral
Functional infection
Disorders • Mumps,
• Xerostomia, • HIV
• Sialorrhea associated
(Ptyalism) salivary
gland
disorder
Developmental disorders

 Atresia is the congenital occlusion or absence of salivary

ducts which leads to xerostomia or mucous retention cyst.

 Aplasia is the complete absence of one or more salivary

gland which leads to xerostomia, and affected patients are
more susceptible to dental caries.
- This condition could be an isolated finding or associated with
other disorder like hemi-facial microsomia or Treacher Collins
syndrome.
- Enamel hypoplasia, extensive occlusal wear of teeth or
congenital absence of teeth are other oral manifestations of
 Aberrancy:
salivary It is an anatomic variant wherein the normal
agenesis.
salivary gland develops at an abnormal position.
- Sometimes they are found adjacent to lingual surface of the
mandible within a depression.
- Ex: Staphne’s bone cyst or Staphne’s bone cavity
Inflammatory Conditions
Acute Bacterial
Sialadenitis
 Parotid gland is the most common salivary gland involved
 Organisms - Staphylococcus aureus,Streptococcus pyogenes,
Streptococcus viridans, Pneumococcus,Actinomycetes
 Etiologic factors -
• Reduced salivary flow
• Old age,
• After a major surgical procedure where in the patient depends only
on intravenous fluids.
• Patients with medication on tricyclic antidepressants and
tranquilizers.
• It may be retrograde contamination of salivary ducts and
parenchymal tissues by oral microflora providing a bacterial source of
infection.
Clinical features -
• Pain and swelling
• Generalized malaise, fever, body ache.
• Diffuse inflammatory swelling, induration, erythema, edema, and
extreme tenderness over the affected gland.
• Tense, glossy, and erythematous skin.
Clinical Features -
• Raised ear lobule is pathognomonic sign of parotid swelling.
• The duct orifices are inflamed, and milking of gland may exhibit
lesser salivation or purulence.
• Parotid swellings are not fluctuant due to fixity of overlying investing
parotidomasseteric fascia and are extremely painful.
• The cellulitic phase may not yield any frank pus, but toxic fluid is
drained and it releases the pressure over the gland and prevents
pressure necrosis of the gland parenchyma.
• Parotid space abscess has the tendency to spread into the
parapharyngeal spaces and cause respiratory distress and
descending mediastinitis or burst into the auditory canal .
 Diagno
sis
 The leukocyte count is high—leukocytosis.
 The pus is collected from Stenson’s duct taking care not to
contaminate the swab with oral microfloa, for the culture and
sensitivity tests.
 Sialography is contraindicated in cases of acute infections .
 Aspiration might not yield frank pus.

Management

- The condition usually resolves in about 48 h.

- Antibiotics
- Palliative
• Hydrating the patient
• Stimulate the salivation by chewing sialogogues
• Improve the oral hygiene by debridement and irrigation.

- If there is no improvement, surgical drainage may be done using

needle aspiration guided by CT scan or ultrasonography.
 Chronic Bacterial Sialadenitis

• It is a recurrent sialadenitis with

episodic relapsing swellings
• Most commonly seen in the
parotid gland.
• Etiology-
- Salivary retention and stasis
- Might be preceded by an acute
sialadenitis.
Chronic bacterial sialadenitis of
- Duct obstruction left submandibular gland
- Sjögrens syndrome

• The microorganisms may be

Streptococci viridans, E. coli,
Proteus or Pneumococci

• Symptoms
- Starts as a unilateral swelling at the
angle of the jaw.
- Low grade fever, and
- Salivary gland milking may yield
scanty saliva.
 Manageme
nt
- Intraductal infusion of antibiotics

- Sialoendoscopy can play a role in

increasing the salivary flow.

The sialoendoscope is advanced

slowly into the duct with continuous
saline irrigation to help visualize the
system.

This is followed up by placing a stent

into the duct for 4 weeks.

- Superficial parotidectomy with facial

nerve preservation can also be
considered in case of chronic pain.
 Viral Infections of Salivary Glands

Mumps
• Epidemic parotitis.
• It is an acute nonsuppurative viral
parotitis caused by paramyxovirus.
• The term “mumps” is derived from
the Danish word “Mompen”

Pathogenesis
- Spreads by airborne droplet
dissemination.
- Incubation - 2–3 weeks.
- The virus localizes - salivary glands,
germinal tissues, and CNS.
Clinical Features -
- Predilection for the parotid gland.
- Highly contagious
- Occurs in children < 15 years of age with peak incidence being in the 4-
to 6-year-old group of children.
- Adults are rarely infected due to the immunity.
- Headache, fever, arthralgias, and malaise prior to development of
parotitis.
- It starts with an earache, pain around the gland, trismus, and
dysphagia.
- Pain is increased by salivary stimulation during meals.
- Inflamed and puffy parotid papilla.
- Palpation - swelling may be tense, rubbery, and firm with non-
pitting-type edema.
- Overlying skin - tensed and shiny without erythema.
- Swelling lasts for 1–5 days.
- It peaks during the first week and starts declining in the second or
third week Glands of both the sides enlarge,
- Xerostomia, trismus, cervical lymphadenitis.
which may be simultaneous or
one following the
other in 24–48 hours.

Patients are contagious up to 14

days after the resolution of the
symptoms.
Diagnosis

- Acute phase - Serum amylase levels

- Blood count shows leukocytopenia with relative lymphocytosis.
- A fourfold rise in antibody titer is diagnostic of active infection.

Treatment

• It is self-limiting,
• Symptomatic relief can be given by antipyretics.
• Antibiotics can be given to prevent the secondary infection.

Prevention:

 Live attenuated Jeryl Lynn vaccine is given combined with

measles and rubella as MMR vaccine .
 The first dose - 9 months to 15 months of age, with a second
dose - 15 months to 6 years of age, with at least four weeks
between the doses.
Functional Disorders

Sialorrhea or Ptyalism

• It is excessive salivation seen in

affected patients.
• Mild, Intermittent or Continuous
profuse drooling.
• Severe drooling, choking and social
embarrassment to the patient.
• Minor - local irritation like aphthous
ulcers or illfitting dentures.
• Idiopathic paroxysmal sialorrhea will
have short episodes for 2–5 minutes.
• Profuse - rabies, heavy metal
poisoning or medications like lithium
and cholinergic agonists.

In Neurologically disabled persons

(cerebral palsy)
- Muscle incoordination inhibits the
initiation of the swallow reflex
 Management

• Management can be conservative or more invasive.

•
• Conservative -
- Anticholinergic medication like Glycopyrrolate
- Behavioral modification
- Physical therapy.

• Surgical Treatment
- Salivary gland resection
- Transposition of parotid duct
- Parotid duct ligation

• Tiigimae-Saar et al., in 2012, injected botulinum neurotoxin type

A into the major salivary glands to produce xerostomia. It
reduced drooling but required GA and the effect lasted for only 2
months.
 Xerosto
mia
• Women > men,
• Older people,
• Medication -Antihistamines,
antidepressants, anticholinergics
• Salivary gland aplasia, excessive
smoking, mouth breathing, radiation
therapy, Sjögren’s syndrome.

• Clinically feature -

- Dry mouth with foamy, thick, ropy

saliva can be noticed.
- Leathery appearance and fissures with
atrophy of the filiform papillae.
- Patients are more prone for oral
candidiasis due to reduction in cleansing
and antimicrobial action of saliva.
- Dental decay is rampant with more of
cervical and root caries.
Management

• Treatment is conservative,
• Maintenance of oral hygiene,
• Use of sialogogues (pilocarpine),
• Systemic pilocarpine—5–10 mg, 3/4 times daily,
• Sugarless gum chewing,
• Topical fluoride application to the teeth,
• Bromhexine 8 mg tds in adults,
Obstructive Disorders
Sialolithiasi
s
 Sialolithiasis is the formation of
sialolith in the salivary duct or the
gland resulting in the mechanical
obstruction of the salivary flow.

 Submandibular gland and

duct(80%); Parotid gland(20%)

 Etiology
- Dehydration & Reduced food intake
- Medications - antihistamines,,
antidepressants & anticholinergics
- Gout - uric acid calculi
- Aging, inflammation, local irritation,
- Sjögren’s syndrome
- Tobacco smoking
- Radiotherapy
Clinical Features

- Symptomatic calculi are much lesser in occurrence.

- Common location - The right-angle bend of the Stenson’s duct where
it pierces the buccinator and the 90° bend of the Wharton’s duct at
the border of the mylohyoid.
- Meal time syndrome
- There is inability to milk saliva from the duct orifice.
- Bimanual palpation/examination, of the floor of the mouth, along the
duct, may reveal the presence of the stone.
- May be firm, palpable mass in the duct or gland, particularly in the
most peripheral
portion of the duct.
Diagnosis

- Radiographs : 80–90% submandibular stones are radio-

opaque; 50–80% parotid stones are radiolucent.
- Ultrasonography- can detect small greater than 2 mm
stones
- Sialography
- CT scan - identifying stones in the hilum or
parenchyma of the affected salivary gland
Management

- Smaller stones - local massage, sialogogues, and adequate

hydration.
- Larger stones are managed surgically according to its location in
the duct and gland.\

• Submandibular sialoliths :
- Mobile stones < 5 mm located within the distal duct - endoscopy.
- Stones of 5 to 7 mm within the proximal duct or hilar region should
receive initial treatment endoscopically. If this is unsuccessful or the
stone becomes impacted, the next step is a transoral surgical
approach.
• Parotid Sialoliths-

- < 7 mm and are mobile require endoscopic removal.

- If endoscopic management is unsuccessful or the stones have

become impacted, external shockwave lithotripsy is considered
the most appropriate second-line therapy with subsequent
endoscopic removal of fragmented stones.

- Treatment of salivary stones that do not respond to external

shockwave lithotripsy is with a combined transcutaneous and
endoscopic approach (assuming the stone is visible under
endoscopy).

- Surgical excision of the parotid gland should be a last resort

• Lithotripsy reduces calculi to
small fragments that are then
flushed out of the duct with
spontaneous salivation or use
of sialogogue.

- A “gum test” which involves

chewing of a sour gum can be
done to test the functionality of
the salivary gland.

• If the salivary secretions are

normal, a visible swelling in
the region of the gland will be
noticed.
• If the test is negative, the
patient cannot be taken up for
lithotripsy.
 Mucoceles

 It is a benign, mucus-containing cystic lesion of the minor salivary

gland.

 They is caused due to blockage or rupture of a salivary gland duct

mostly due to trauma resulting in spillage of mucin into the
surrounding tissues.

 Etiology- Mechanical trauma, chronic inflammation/irritation (e.g.,

from heat and smoking), excretory duct fibrosis, trauma from
intubation, sialolithiasis of the minor salivary glands.
Mucocele

Extravasation
Retention mucocele
mucocele
- Results from a injured - Appears due to
salivary gland duct and decrease or absence of
consequent spillage into glandular secretion
the soft tissue around produced by blockage of
this gland. salivary gland ducts.
Clinical Features

- Superficial lesions appear like a circumscribed, raised vesicle with a

bluish translucent hue due to the thin overlying mucosa.

- However, deeper lesions being covered by normal mucosa have a

normal color and texture.

- Site of occurrence - lower lip (44–79%)> tongue > floor of mouth >
the buccal mucosa.

- Mucoceles may get traumatized

and rupture spontaneously and
may recur later

-The mucocele may rupture

spontaneously, with the liberation
of a viscous fluid. However, in a
few days to weeks, additional fluid
accumulates and the lesion
reappears.
Management

- Surgical excision of the mucocele along with a few normal minor

salivary glands is the procedure of choice.
- Care should be taken to avoid creation of any other partially
transected minor salivary
glands which might give rise to the recurrent mucocele.
- Mucocele can be excised by giving an elliptical incision around the
lesion ,an incision may be given over the mucocele
 Ranula
 It is a mucocele arising from the
sublingual salivary gland in the
floor of the mouth.
 Large blue, tense vesicle in the
floor of the mouth.
 It is firm on palpation.

 Two types - superficial ranula

and plunging ranula.

• The cyst is usually present above

the mylohyoid curtain, but when it
presents in the upper part of the
neck, it is called as a “plunging
ranula.”

 Etiology- Trauma to the excretory duct

of the major salivary glands
- Obstruction of the duct (sialolith or mucus
plug),
- chronic inflammation ( Sjogren syndrome )
Management

- Excision of the ranula and entire sublingual gland through a

transoral approach is management of choice taking care to avoid
damage to the lingual nerve.

The incision is made through the mucosa in the lingual sulcus from
the first molar
to midline.

Blunt dissection is done up to the mylohyoid muscle.

The gland is dissected free from the surrounding soft tissues and the
Wharton’s duct.

The gland can be retracted using holding sutures, and blunt

dissection is carried out till the lingual nerve is identified as it
crosses the Wharton’s duct.
- Marsupialization can be used as an alternative modality wherein the
ranula is deroofed and the mucosa sutured to the cystic lining followed
by open packing of the cyst and sequentially reducing the size of the
pack till it heals completely.

- Higher recurrence rate

(61–85%) has been
reported with simple
marsupialization and ranula
excision.
Autoimmune Disorders
Mikulicz’ Disease
• Abnormal enlargement of the salivary and lacrimal glands.
• Benign Lymphoepithelial Lesion

Clinical Feature -
- Middle-aged females
- Unilateral or bilateral enlargement of the parotid or
submandibular glands with an occasional or
swelling.
- Mild local discomfort, occasional pain, and
xerostomia.
- Fever, upper respiratory tract infection, tooth
extraction, or some other local inflammatory
disorder may precede the disease.
- Sometimes the lacrimal glands may be enlarged.
- FNAC can help diagnose the condition.
Management
- In some cases, the swelling might regress spontaneously.
- Persistent cases can be managed by sialadenectomy.
 Sjögren’s Syndrome

Sjögren’s syndrome shows a

triad of symptoms—
- Keratoconjunctivitis
sicca,
- Xerostomia, and
- A systemic disease,
usually but not always
•rheumatoid arthritis.
Primary Sjögren’s
syndrome also known as
Sicca complex presents
with only dry eyes and Clinical Feature
xerostomia.
- The female: male ratio is 10 : 1.
- Arthritis is the most frequent first
• Secondary Sjögren’s complaint, followed by ocular
syndrome complaints.
Primary Sjögren’s - Xerostomia which leads to difficulty
syndrome in chewing and swallowing, sore
mouth, recurrent dental caries, and
- Systemic lupus fungal infections in the oral cavity.
erythematosus,
-Tongue - bald with loss of filiform papillae and fissuring of tongue.
-Saliva - cloudy and abnormally viscous.
- Parotid gland enlargement is seen in 25-66% cases of primary
Sjögren’s syndrome but is uncommon in secondary cases.
- Xeropthalmia leads to chronic irritation and destruction of the corneal
and bulbar conjunctival epithelium, referred to as kerato-conjunctivitis
sicca.
- The patient complains of redness, itchiness, or burning sensation in
the eye, rope-like secretions & dryness,
- Dysphagia results from drying of the pharynx and esophagus.

Diagnosis

- Over 75% of the patients show a polyclonal hyperglobulinemia.

- Increased sedimentation rate is present in 80% of patients.
- Schirmer’s test is used to confirm lacrimal secretions.
- The Rose-Bengal dye test is used to detect the damaged and
denuded areas of the cornea.
- The break up time (BUT) is performed using a slit-lamp and noting
the interval between a complete blink and the appearance of dry spot
on the cornea.
- Salivary gland function in suspected cases can be measured by
using parotid flow rate, biopsy and salivary scintigraphy.
- Sialography - “branchless fruit laden tree” or “cherry blossom”
appearance.

Management

- Xerostomia and keratoconjunctivitis sicca are managed by use of

0.5% methylcellulose artificial saliva and tears.
- Preventive dental care and fluoride application and maintenance of
general hygiene are necessary.
- Eye patching and boric acid ointment can be used for corneal ulcers.
Pilocarpine hydrochloride can be used as a secretagouge for
management of xeropthalmia.
- There is no specific treatment for enlargement of the salivary glands.
 Salivary Gland
Tumors

WHO classification of
salivary gland tumors
(2017)
 Pleomorphic
Adenoma
 “Pleomorphic adenoma” suggested by Willis. It is the most
common salivary gland tumor
 The tumor derives its name from the Greek words Pleos = many
and
morphus = form because of the heterogeneous nature of its
histologic
Clinical appearance.
Features

- Most frequently found in the superficial lobe of

the parotid gland, it presents as a firm, slow-
growing asymptomatic mass which is smooth,
rounded, lobular, and mobile with a rubbery
consistency causing ear lobule to be raised.

- If the tumor involves both the superficial and

deep lobes of parotid, it is classically referred to
as dumbbell tumor.

- Females > males, often seen in the fourth

and fifth decade.

- Pain is uncommon but 50% patients

- They are encapsulated and do not show fixity to the deeper tissues
or the overlying skin in major salivary gland tumors.

- Lesions having been recorded which weighed several kilograms

- In the case of the minor salivary glands of the palate, it may appear
to be fixed to the underlying palatal bone but does not invade or
erode the bone.

- In the case of the submandibular gland, palpation of the mass both

extraorally and bimanually helps in localizing it and differentiating it
from a lymph node, but FNAC is always needed to differentiate it from
sialadenitis.
Management

• Superficial parotidectomy is the most widely accepted technique

in the superficial lobe of the parotid gland.

• Submandibular tumors are usually contained within the gland, and

their resection is usually confined to the gland and surrounding fat
or lymph nodes until the neoplasm is a malignant.

• The tumor along with the periosteum of the palate is excised in

continuity with each other.

• In case the pleomorphic adenoma invades the palate or proliferates

into the floor of the maxillary sinus, a partial maxillectomy or total
maxillectomy depending on the extension of the tumor has to be
performed.

Although pleomorphic adenoma is a benign tumor, it may cause

problems in clinical management due to its tendency to recur and risk
of malignant transformation.
 Warthin’s
Tumor
 Warthin’s tumor, also known as papillary cystadenoma
lymphomatosum and adenolymphoma
 It is the second most common benign tumor of the salivary glands,
around 5% of neoplasms.

Clinical Features

- Parotid gland, more often

bilaterally.
- Males > females
- Fifth and sixth decades of
life
- It is a solitary, nodular,
slowly enlarging swelling,
most commonly located in
the inferior pole of the
parotid next to the angle of
the mandible.
- It varies from moderately
firm to fluctuant on
palpation and is
asymptomatic.
Diagnosis -

- May contain mucoid brown fluid in FNA.

- Scintigraphy may be helpful due to its increased uptake of

technetium- 99m pertechnetate.

- It appears as a smooth-margined, radiopositive “hot” nodule in

contrast to the mixed tumors, nonfunctioning malignant tumors, and
metastatic tumors which appear as a “cold” nodule in scintigraphy.

- Positive scintigraphy with 123I is indicative of Warthin’s tumor but

may also signify presence of ectopic thyroid or metastatic thyroid
tumor.
Management

• As the tumor is superficial in the parotid gland, it is easily removed

with minimal loss of glandular function and with preservation of the
facial nerve.

• Preoperative diagnosis of Warthin’s tumor must be confirmed by

coordinating the clinical findings with imaging and fine-needle
aspiration biopsy reports before local excision is carried out.

• Local excision of the tumor is preferred to enucleation of the tumor

because lymph nodes at the posteroinferior part of the gland
cannot be cleared by enucleation.

• If there is associated chronic obstructive parotitis, superficial

parotidectomy is essential.

• Similarly, if the tumor is located in front of the ear, a superficial

parotidectomy is the treatment of choice.
 Mucoepidermoid
Carcinoma
It is the most common malignant salivary gland
neoplasm.
They are classified as
- Grade I (low grade)
- Grade II (intermediate grade)
- Grade III (high grade) .
Clinical Features
• Female predilection.
• It occurs as a slow growing painless,
<5mm in diametre circumscribed,
mobile solitary enlargement of the
body or tail of the parotid or the
submandibular region and minor
salivary gland.
• High- grade - Pain and fixation to the
overlying skin.
- Ulceration and facial paralysis, trismus, drainage from the ear,
dysphagia, numbness of the adjacent areas
- Tends to infiltrate the surrounding tissue, and in a large percentage of
cases, it metastasize to regional lymph nodes. Distant metastases to
lung, bone, brain and
subcutaneous tissues are also common.
Management

• Complete, adequate, and radical surgical excision is the treatment of

choice.
• Stage I and stage II (parotid gland) - conservative excision with
preservation of the facial nerve, if possible, is recommended.
• Submandibular gland - removed entirely.
• Radical neck dissection is performed in patients with clinical evidence
of cervical node metastasis and is considered in any patient with a T3
lesion.
• In the case of facial nerve involvement, total parotidectomy with
facial nerve sacrifice up to histologically tumor-negative nerve trunk
is done.
• Minor salivary gland - wide surgical excision with the bone if involved,
to achieve a negative margin.
• The overall recurrence rate of mucoepidermoid carcinomas is
approximately 25%.
• The 5-year disease-free rate in patients receiving this aggressive
treatment was about 60%.
• Better survival is seen among younger patients and among females.
 Adenoid Cystic
Carcinoma

• Adenoid cystic carcinoma (ACC) is a highly aggressive, destructive,

and with high reccurence
• The other terms used for ACC used in the past are cylindroma and
adenomyoepithelioma.

Clinical Features

- Age- 50 and 70 years

- Equal prevalence in males and females.
- Most frequent locations - parotid, submandibular, and palatal
salivary glands.
- A slow-growing swelling
- Early local pain, facial nerve paralysis (parotid tumors), fixation to
deeper structures and local invasion.
- Intraoral ones, exhibit surface ulceration.
- Tendency to spread through perineural spaces and usually invades
well beyond the clinically apparent borders.
Management

• Treatment of choice - radical surgical excision with histologically

proven negative margins with postoperative radiotherapy.
• Elective regional lymph node dissection is not indicated
• A frozen section diagnosis to achieve tumor-free safe margins is
necessary to specifically look for safe perineural margins because
ACC is known to spread quickly along the nerve.

The slow biologic growth of adenoid cystic carcinoma along with a late
metastasis of the disease results in relatively favorable 5-year survival
rates.

• Poor prognosis - failure to achieve clear margins at first surgery, a

solid pattern histologically, recurrent disease, and distant metastasis
.
• Recurrences have been seen in almost 32% of the cases.
• The risk of distant metastasis is also high, approximately 40%, and
can occur in less than 8 years after treatment.
DIAGONOSTIC AIDS
Diagnostic imaging plays an important role in the evaluation of various
disorders of major salivary glands.

The modalities used for imaging include:

- Conventional radiography
- Sialography
- Ultrasonography
- Computed tomography
- Radionucleotide imaging
- Magnetic resonance imaging (MRI).
 Sialography
• The technique was first performed by Carpy in 1902, using mercury
as the contrast agent.
• It assesses obstructive pathology by instillation of radiopaque
contrast medium to locate obstruction in the ductal system.
• It is a technique which involves injection of a radiopaque dye into the
ductal system of the major salivary glands and taking plain X-rays to
see the pattern of the dye into the ductal systems.
• Most commonly the contrast dyes used are iodine based.
• Lyophilic (oil-based) contrast dyes -Lipiodol (iodized poppy seed oil)
and Pantopaque (organic iodine compound), Ethiadol.
• Aqueous contrast dyes - hypaque , hypaque M , renografin 60 and
metrizoate (Triosil).

• Indicated-
- Obstructive pathologies and duct anomalies,
- Degenerative changes in the gland,
- Chronic inflammatory conditions, and
- Intra- and extraglandular tumors.
Contraindication-

- Patients with a known allergy or hypersensitivity to iodine

compounds; and/or other radiographic contrast media.
All patients referred for sialography should be asked about possible
previous adverse drug reactions to iodine or other radiographic
contrast media.
These reactions include: marked urticaria, dyspnea, asthmatic attacks
and anaphylaxis.

- During the period of acute inflammation/infection of the salivary

glands (e.g. acute suppurative sialadenitis).
In this condition, sialography is contraindicated, because:
■ The contrast media cause irritation.
■ There is increased chance of rupture of duct and extravasation of
contrast media into already inflammed gland.
■ There is a potential for retrograde dissemination of pyogenic
organisms throughout the gland.
Procedure:

The duct orifice is enlarged using a lacrimal probe and cannulated with
a cannula

The selected dye is injected into the ductal system using a syringe with
gentle continuous pressure with simultaneous massage of the gland.

Once the patient feels some discomfort, dye injection is stopped. X-rays
are taken during the filling phase and emptying phase as well.
The X-rays show different patterns:

1. The normal parotid gland shows “tree in winter” or “leafless tree”

pattern,

2. Submandibular gland shows “bush in winter” appearance. This is

because the normal acini do not allow dye to enter and it is seen only
in the ducts and ductules.
3. Sialolithiasis shows filling defect .

4. Sjögren’s syndrome and Mikulicz’ disease show a “snow storm” or

“branchless fruit-laden” appearance.
 5. In chronic inflammation the dye enters the ductules, and the empty acini give a
“blossom tree” or “leafy tree” appearance.

Multiple strictures show a sausage appearance.

7. “Cannon ball” appearance is seen in intraglandular tumors, whereas
extraglandular tumors show a “ball in hand” appearance.
 REFERENCES

• Oral and Maxillofacial Surgery for the Clinician by K.

Bonanthaya et al.
• B.D Chaurasias Human Anatomy-Volume 3 Head Neck and
Brain (6th_Edition)
• Head and neck anatomy for dental medicine / edited by
Eric W. Baker
• McEwen DR, Sanchez MM. A guide to salivary gland
disorders. AORN J. 1997 Mar.
• A guide to salivary gland disorders by RON BOVA
• Textbook of Oral and Maxillofacial Surgery Textbook of
Oral and Maxillofacial Surgery