Saliva is not one of the popular

body fluidsIt lacks the drama of blood,

Sincerity of Sweat and
The emotional appeal of tears.
-William Shakespeare

Three paired glands

Parotid
Largest of the major salivary glands
Two Lobes divided by facial nerve
Submandibular gland
Deep to mylohyoid, superficial to
hyoglossus
Sublingual
Smallest of the salivary glands
Minor salivary glands
2

Keeps the mouth moist-lubricates food and

mouth during chewing, swallowing and phonation
Renders food substances soluble-thus aiding in
taste sensation
Digestion of starch in the diet is first by amylase ptyalin in the saliva
Noxious substances increase the salivary
secretion there by help in diluting the noxious
stimuli
Bicarbonate & protein contribute to the
buffering power of saliva-restores physiologic pH
of the oral cavity
Recent studies have shown the saliva to have
anti viral properties-helps in maintaining tooth
integrity
May be used as a diagnostic tool in
monitoring physiologic disorders and
systemic
7
hormone & drug levels.

Protective & Anti bacterial Functions:

Salivary mucins (glycosaminoglycans) coating
the oral mucosa protect against the harmful
effects of noxious stimuli, Microbial toxins &
minor trauma. This coat traps the microbes
and transfers them to the stomach where the
acidic Ph of the gastric juice degrades them.
Lysozyme-an enzyme that has little effect on
the normal flora inhibits the noncommensals
by combining with IgA immunoglobulin and
lyses the bacteria.
Thiocynate dependent factors the presence of
which increases the chances of oral
malignancy is increased with decrease in
saliva as seen in smokers and tobacco
8

now questioned
Lactoferrin-binds with the available iron and
does not
allow it to enter bacterial metabolism.

Antifungal property-by a histidine rich

peptide-inhibits
candidal growth.

Mucosal antibodies & salivary mucins

secreted by the
submandibular gland has demonstrated
antiviral
properties- anti HIV and Anti-HbsAg.

EFFERENT PATHWAYS
PARASYMPATHETIC

SYMPATHETIC

Parotid

Alpha & Beta Fi

Glossopharyngeal (IX)- to Tympanic

-to Otic ganglion

Superior Cervical Gang

Postganglionic-through auriculotemporal nerve.

Submandibular, Sublingual
Chordatympani (VII)-Submandibular ganglion with
Lingual Nerve to Sublingual Gland.

10

through a

INFLAMMATORY
Viral
Bacterial (supparative)
Granulomatous
Mycobacterium
Actinomycosis
Sarcoid

II

OBSTRUCTIVE SALIVARY GLAND DISEASES

Sialolith (sialolithiasis)
Mucocele
Mucous retention cyst (Ranula)

III

AUTOIMMUNE
Begnign lymphoepithelial disease
Sjogren`s syndrome

IV

ASYMPTOMATIC PAROTID HYPERTROPHY

11
Sialosis

Sialosis:

Non neoplastic and non inflammatory

enlargement of salivary glands

Sialadenitis:

Inflammation of salivary glands

Sialodochitis:

Inflammation of salivary duct

Xerostomia:

Salivary production < 0.2ml / min

HypoSialorrhea: Diminished salivary production

< Normal but more than 0.2 ml / min
12

Sialolithiasis: Calculi / stone in duct or gland

Sialactesis: Atrophy of total / part of salivary gland
Ptyalism: Excessive secretion of saliva > 4 ml / min

13

APTYALISM / DRY MOUTH SYNDROME

Etiology:
Irradiation
Age
Major surgery of Salivary gland
Hypoprotenamia / Hypovitaminosis
Drugs:
Diuretics
Anticholinergics
Antihistamines

14

COMPLICATIONS:

Dental caries

Periodontitis

Mucositis

Oral candidiasis

Dysphagia

Speech problems

Halitosis

Denture retention

15

MANAGEMENT:
Use of water or gels
Lozenges / sour candies
Non fermentable carbohydrates
Saliva stimulating agents
Glycerol
Lemon juice

Oral hygiene
Chewing gums (Fluorides)
Hexidine mouth washes

Artificial saliva (lacks mucus)

16

Formation of calcific concentration within

the ductal
system of a major / minor gland.
FACTORS:
Salivary stagnation
Nidus / Matrix for stone formation
Aggregates of bacteria
Clumps of epithelial cells
Blebs of mucus
Blood clots following trauma
17
Small foreign bodies

Metabolic mechanism favoring precipitation

of salivary salts into matrix.

More common in Submandibular gland system

Saliva is more alkaline
Contains greater concentration of calcium
and phosphate salts in the form of
appatite's
Longer duct
Located at a lower level than its orifice
uphill course
Composition: Ca3(Po4)2 -74.3 %

18Organic

Total absence of symptoms -- Routine

radiographic examination
Eating initiates intermittent transient
swelling of the involved gland ,
accompanied by moderate discomfort.
Patient is comfortable, concerned about
recurrent swelling
Gelatinous cloudy mucopus / basically clear and
adequate saliva.
Derived from inflammatory ductal changes
19

Pronounced exacerbation characterized by

acute supparative process with systemic
manifestations fever / malaise
Pus exudes from ductal orifice
soft tissue around duct
inflammed
Gland enlarged, tender and
tense
pain salivation /
mastication
20

Digital manipulation:
Gland firm and larger
Produces flow of saliva visual inspection of fluid
Location of hard calcific stone along ductal
course
Yellowish colour of calcific deposit seen through
distended and thin mucous membrane
Metallic probe grating sensation

21

Radiographs
Sialography

22

1. Calculi Localized

2. Incision in the floor of the mouth directly over th

23

Exposure of the duct

Temporary ligature passed proximal & distal
Duct opened by longitudinal incision
Calculus removed
Mucosal incision sutured

24

25

26

 Detection of a calculus / calculi / foreign body

Determination of the extent of destruction of gla
to obstructing calculi / foreign body

Detection of fistulae , diverticuli or strictures

Detection / diagnosis of recurrent swelling and in
processes
Tumor location / size
Selection of a site for biopsy
Outline the plane of facial nerve
Residual stone / tumor, fistula or stenosis
27

28

 Known sensitivity to Iodine compounds

Acute inflammation of salivary system
Interfere with thyroid function tests

29

IDEAL REQUISITES:
Physiologic properties similar to saliva
Miscibility with saliva
Absence of systemic / local toxicity
Low surface tension and low viscosity
Easy elimination
Absorption and detoxification

30

 Lower viscosity
Lower surface tension
More miscible with saliva
Filling finer ductal system under
lower pressure
Facilitate prompt drainage
Less pain / discomfort
No significant Granulomatous reaction
Residual contrast media absorbed and
excreted through kidneys
Opacity is not good reduced contrast
31

Hypaque 50%

--

Diatrizoate sodium

--

Diatrizoate

50%
Hypaque-M75%
meglumine 50%
Diatrizoate sodium 25%
Renografin

--

Diatrizoate

meglumine
32

 Satisfactory degree of radiographic

opacification
Extravasation severe foreign body
reactions
More viscous higher injection pressure
Greater discomfort
Iodized
oil
Water Insoluble
Poorly
eliminated
Organic
iodine
compounds
Ethiodol - Ethiodized
poppy seed oil
Pentopaque
Lipidol - Iodized poppy
33
seed oil

Parotid gland:
Stenson`s duct 1-3mm in width, 6cm length
Branches gradually and smoothly into
second and third order ductules
In A-P view, it is 2cm lateral to the mandible.

34

Submandibular gland:
Wharton's duct is 5cm in length, lumen 24mm wider than parotid.
External orifice is smaller.
Submandibular Acini are more rapidly filled
Acini are larger
Wall of the duct is thinner and offers less
resistance
Second and third order ductules are short,
more accessible to media.

35

Ductal changes:
Calculus: Plain films Occlusal views
Cheek blow out A-P view
Open mouth Lateral
view
Filling defects in main duct distal to calculus,
lobules are overfilled.
Ductal dilatation caused by associated
Sialodochitis
Emptying film shows retained contrast media
36

37

Sialodochitis:
Segmental strictures & dilation of larger
ducts.
sausage string appearance
Acini & ductules are not dilated

38

Glandular changes:
Sialadenitis:
Sacular dilatation of the acini & terminal
ducts.
Main duct & inter lobular ducts appear normal
in caliber.

39

Sjogren`s syndrome:
Wide spread dots / blebs within the gland.
Snow storm appearance.
Due to the wearing of epithelial lining the
intercaleted ducts allow escape of contrast
media.

40

Tumours:
Extrinsic Glandular architecture preserved
but displaced.
Acini are compressed & ducts are intact.
Emptying phase Ductal system empties
normally, because glandular parenchyma is
normal.
Intrinsic: Normal ductal & acinar architecture
is completely replaced by prowing of contrast
media.
41

Definition
Inflammatory condition of Salivary
gland.
Acute/ Chronic (recurrent)

Etiology & Types:

Allergic

Viral

Post
Irradiation
Granulomatous

Supparative

Mycobacteri
um
(Bacterial)
Sarcoid
Actinomycos
Ductal
Reduction
is
Obstruction In salivary
42
secretion

Mumps

Approach:

Care complete history

Determine Acute / Chronic
Isolate infection / cause
Clinical examination
-Complete

:Head & neck

:Salivary glands
:Milking of gland
:Gentle probing / Ductal

dilatation
43

Mumps:
Non supparative ,acute, contagious,
generalized viral disease.
Painful enlargement of parotids
Spread Airborne droplet infection from
saliva
Incubation period: 2-3weeks after exposure
Avg: 17 18 days
Pain & swelling in one / both parotids
Exacerbated by stimulation of the gland
Minimal erythema around ductal44orifice,

Associated fever, muscular pain, headache

Subside in 3-7 days
Diagnosis:
Parotitis + systemic signs
Leucopenia,
Serum Amylase
Treatment:

Symptomatic

Complications:
Meningocephalitis
Orchitis
Pancreatitis
45

Bacterial sialadenitis :
Acute bacterial sialadenitis :
Uncommon disease
Affects commonly the parotid gland
Less commonly affects submandibular
gland.
Synonyms :
Acute supparative parotitis / acute
parotitis
46

Causative organism :
Penicillin resistant stap-aureus
streptococcus viridians,
and streptococcus pneumoniae.
Less commonly hemophilus and
bacteroid groups
may be involved .
Route of spread of infection :
In case of acute Parotitis, the
infection is usually
of ascending type
and the bacteria reach the gland via
47
Stensons duct.

Predisposing factors :

Previous major surgery (especially

abdominal surgery).
Debilitated and dehydrated patients.
Diabetes
Malignancy
Premature born infants
Drugs which decrease salivary flow
Sjogrens syndrome
Immunocompromised patients
Trauma to the duct system
48
Hematogenous spread of infection
from

Clinical features :

Sudden onset painful swelling in the

preauricular region.

Parotid gland involved either

unilaterally/bilaterally.

Fever, malaise, headache and redness of

the skin overlying the parotid.

Trismus and difficulty in swallowing.

I/o parotid papilla may be inflamed and

often Pus/exudates may be expressed from

the duct opening.

49

Lab investigations :
Elevated ESR and leucocyte
Bacterial culture from saliva/parotid
secretions
Treatments
:
Goal :
Eliminate causative organism,
Dehydration of patient,
Drainage of purulence
Empirical antibiotic therapy
Pencillinase resistant antibiotic
such as
semi synthetic penicillin.
Analgesics
Bed rest
Drainage.
50

CHRONIC BACTERIAL SIALADENITIS :

It is a nonspecific inflammatory disease of
the salivary gland secondary to duct obstruction
or low grade sustained
ascending infection.
Clinical features :
Occurs in adults and childrens
Commonly affects parotid gland
Usually unilateral
Recurrent tender swelling of the affected
gland is a
common feature
Duct orifice will be inflamed and in case
of acute exacerbation, there can be
purulent discharge from it
51
Decreased salivary flow.

52

Investigations :
Sialography
Radiography
Bacterial culture from saliva / secretion of
the gland
Biopsy.

Histopathology :
Acinar atrophy of the salivary gland with subseq
Dilatations of the ductal system
Hyperplasia of ductal epithelium
Chronic inflammatory cell infiltration
53

RECURRENT PAROTITIS :
Rare condition
Affects children and adults.
Predisposing factors :
Salivary gland calculi structure of the duct.
Abnormal low secretion of saliva due to any
cause.
Congenital absence of duct system
Immunosuppression
Clinical features:
Unilateral / bilateral.
Recurrent painful swelling of affected gland.
Discharge of pus from the duct orifice.
54

Cystic lesion developing

salivary glands are commonly
mucoceles.

from the
known as

Develop mostly in -- minor salivary glands and

rarely, in relation to the major salivary glands.
Mucoceles are of two types :
i) Mucous retention cyst
ii) Mucous extravasation cyst.
55

MUCOUS RETENTION CYST :

( mucus duct cyst / sialocyst)
Etiopathogenesis :
Obstruction to the duct of the minor
salivary gland, Accumulation of saliva within
the gland / its duct, there by causing
expansion.
Calculus formation,
Scarring,
Crushing of the duct (as a result of trauma) and
Atresia (congenital absence of duct in the
salivary gland), or Impinging tumor etc
56

Clinical features :
Less common than extravasation
phenomenon.
Usually appears in older age group
Commonly seen in the upper lip, check,
and floor of mouth.
Presents as an asymptomatic swelling
without antecedent trauma.
The overlying mucosa is intact and of
normal color.
Mucin in floor-of-mouth lesions may
penetrate musculature and escape into
the soft tissues of the neck, causing a
plunging ranula.
57

The cavity is lined by normal ductal

epithelial cells.
The type of epithelial lining cells ranges
from pseudo
stratified to stratified
squamous.
The cyst lumen contains mucin / calcified
sialolith.
The connective tissue
around the lesion is minimally inflamed,
although the associated gland shows
obstructive change

Differential diagnosis :
Salivary gland neoplasms
Mucus extravasation
phenomenon
Benign connective 58
tissue

Treatment and prognosis :

Requires removal of the mucus retention
cyst and the associated minor salivary gland to
avoid postoperative mucus extravasation
phenomenon.
Lesions of major salivary glands can be
treated in a similar way or, on occasion, only
by removal of the obstruction (sialolith) if it
occurs in the distal part of the ductal system.
The sialolith is either surgically removed/
milked through the duct orifice.
Marsupialization

59

RANULA :
Definition :
Ranula is a form of Mucocele that
specifically occurs in the floor of mouth, in
association with the duct of the sublingual
salivary glands/ rarely the submandibular
gland.
Ranula is Latin word
Rana Frog, because the swelling may
resemble a frogs translucent underbelly.

60

Etiology :
Obstruction of the duct by calculus
(sialolith)
Compression of the duct by trauma or a
growing tumor in the vicinity.
Perforation of the duct due to injury.
Absence of the duct itself (atresia).
Scar / stricture formation to the duct,
especially after surgery.

61

Clinical features :
Appears as a blue, dome-shaped,
fluctuant swelling in
the floor of mouth.
Deeper lesions may be normal in color.
Ranula tend to be larger in diameter
when compared
to mucocele in other
parts of oral cavity.
They can develop into large masses that
are many
centimeters in diameter, fill
the floor of mouth, and elevate the tongue.
62

An unusual clinical variant, the

plunging/cervical
ranula, occurs when the
spilled mucin dissects
swelling within the
neck.

The ranula is usually located lateral to

midline a distinguish feature to the dermoid
cyst.

Like other lesions it can rupture and reform again

63

Treatment and prognosis :

Removal of the feeding sublingual gland
and / or Marsupialization.
Marsupialization (exteriorization) entails
removal of the roof of the intraoral lesions,
potentially allowing the sublingual gland ducts
to reestablish communication with the oral
cavity.
However, this procedure is often unsuccessful,
and most authors emphasize that removal of the
offending gland is the most important
consideration in preventing a recurrence of the
ranula.
64

Mucus extravasation phenomenon :

Etiology and pathogenesis :
The cause of mucus extravasation
phenomenon is traumatic severance of a
salivary gland excretory duct, resulting in
mucus escape, or extravasation into the
surrounding connective tissue.
An inflammatory reaction of neutrophils
followed by macrophages ensues.
Granulation tissue forms a wall around
the mucin pool, and the contributing salivary
gland undergoes inflammatory change,
ultimately scarring occurs in and around the
gland.
65

Appears as dome shaped mucosal

swelling that can range from 1 to 2 mm

to several cm in size.

Common in children and young adults.

Also reported in newborn infants and

older people.

The spilled mucin below the mucosal

surface often imparts a bluish translucent

hue to the swelling, although deeper
mucoceles may be normal in color.

The lesion characteristically is

fluctuant, but some mucocele feel

firmer
66

several years.

H/o a recurrent swelling that

periodically may rupture and release its

fluid contents.

The lower lip is the most common site of

occurrence accounting for about 60%.

Mucoceles are usually found lateral to

midline

Less common sites includes the buccal

mucosa, anterior ventral tongue, and floor

of mouth (ranula).

67

The superficial mucocele, develops as a

single / multiple tense vesicles that measure
1-4 mm in diameter.

The lesions often burst, leaving shallow,

painful ulcers that heal within a few days.

The deep-seated lesions usually cause

small but diffuse swellings, with no color
change in the overlying mucosa.

68

69

70

WHO Classification of salivary gland Tum

ADENOMAS

Carcinoma

Acinic cell carcinoma

Pleomorphic Adenoma
Mucoepidermoid carcin
Myoepithelioma

Basal cell Adenoma Adenoid cystic carcino

Basal cell carcinoma
Warthins Tumor
(Adenolymphoma)

Sebaceous carcinoma

Oncocytoma

Salivary duct carcinom

Sebaceous adenoma Myoepithelial carcinom

Squamous cell carcino
Ductal Papilloma
71

Non Epithelial Tumours

Malignant Lymphomas
Secondary Tumours
Unclassified Tumours
Tumours like lesions
Sialadenosis
Oncocytosis
Necrotizing Sialometaplasia
Benign Lymphoepithelial Lesions
Salivary gland cysts
72

Pleomorphic Adenoma
(Pleos, Many ; Morphus, Form)
Most common of all salivary gland Tumours
It is seen in Major glands
Parotid in 80%
Occur in superficial lobe

Histiogenesis
Myoepithelial cell
Morphologic diversity of tumour including pr
Fibrous, mucinous, chondroid & osseous area

Reserve cell in intercalated duct

Differentiate --- myoepithelial cells
---- metap
73

Pleomorphic Adenoma
The pleomorphic adenoma or benign mixed tumor
is the most common of all salivary gland neoplasms.
It comprises about 70% of all parotid tumors,
50% of all submandibular tumors,
45% of minor salivary gland tumors but
only 6% of sublingual tumors.
The most common location of occurrence is the parotid
(85%) followed by the minor salivary glands (10%),
in which the palate, upper lip and buccal mucosa are
most commonly affected.
Diagnosed in the 4th to 6th decades of life and are
Uncommon in children although they are second only to
hemangiomas in this population.
They are seen more frequently in women with a femaleto-male ratio of 3-4:1.
74

Clinical features:
4th - 6th decade of life
Small pain less nodule, which
enlarges slowly
Does not fix to deeper tissues /
overlying skin
No pain, pressure sensation / local
discomfort
Facial nerve involvement rare
Smaller lesions <1cm usually round ,
homogenous appearance
75

Malignant transformation 2 4 %
Accelerated growth rate
irregularity on palpation
Necrosis & painful ulceration
Facial nerve involvement
Dumbbell tumours into pharyngeal
space is rare
= 1 1.4 %of tumours
80 90 % are Pleomorphic adenomas
76

Warthins tumour / Adenolymphoma

(Papillary Cystadenoma Lymphomatosa)

Mostly Parotid
Arises in the salivary gland tissue entrapped with
Para parotid and intra parotid lymphnodes.
Develops from salivary duct within a lymph node
Delayed hypersensitivity disease
Clinical features:
Middle aged / Elderly males
Pain less
Lower pole of parotid well down below the ear
overlap SCM
Superficial placed
77

Histological features:
Two components Epithelial
Lymphoid
Adenoma exhibiting cyst formation with
papillary projections into the cystic spaces
and lymphoid matrix showing germinal
centers.

78

Mucoepidermoid carcinoma
Most common tumour of salivary gland
origin
Ductal epithelium
Squamous

Differentiate
Metaplasia

Mucous
Rarely encapsulated -ses the possibility
of spillage
3rd 5th decades
Most frequently malignancy of the 79
child good

Histologic Grade
Low grade
2/3rd

Criteria
Well formed glandular structures or microcysts lined
by a single layer of mucus-secreting columnar cells
May have papillary infoldings

Solid areas of epidermoid cells or squamous cells with

intermediate basaloid cells
Intermediate grade
Papillary cystic infoldings of epidermoid or basaloid
cells

High grade

Majority of cells are solid nests and cords of

intermediate basaloid cells and epidermoid cells
Prominent nuclear pleomorphism
Cystic component usually < 20%
Rare glands although occasionally the glandular
component may predominate
More mitotic figures (usually >4/10hpf), necrosis, and
perineural invasion
80

Adenoid cystic carcinoma /

Cylindroma:
Extremely slow rate of growth
Striking tendency to infiltrate locally in
tissue planes between muscle facsiculi well
beyond naked eye.
Marked prone-ness to infiltrate and spread
along perineural spaces
6th 7th decade
Most common of all minor salivary gland
malignancies
81
In major salivary glands
2 -6 %0f

May invade medullary bone without stimulating re

Destruction seen on radiographs is not a reliable g

extent of bone involvement
Metastases lymph nodes and lungs

82

TNM classification for salivary

gland malignancy
Tx Minimal requirement to assess
the tumor is
not met.
TO

No evidence of primary tumor

Tis

Carcinoma in situ

T1

2 cm / less in
greatest dimension without
extraparenchymal extension
83

T2

> 2 cm but < 4 cm in

greatest dimension without
extraparenchymal
extension.
T3
> 4 cm but < 6 cm in greatest
dimension.
Tumor having extraparenchymal
extension
without seventh nerve
involvement
T4
Tumor invades base of skull,
84
seventh nerve,
and/or exceeds
6

NODAL INVOLVEMENT
Nx

Cannot be assessed

N0

No evidence

N1

Evidence of nodal involvement

DISTANT METASTASIS
Mx

Cannot be assessed

M0

No metastasis

M1

Distant metastasis

85

Stage 1

T1
T2

No
No

Mo
Mo

Stage 2

T3

No

Mo

Stage 3

T1
T2

N1
N1

Mo
Mo

Stage 4

T4
T3
T4
Any T
Any T
Any T

NO
N1
N1
N2
N3
Any N

M1
Mo
Mo
Mo
Mo
M1
86

Tumour Type
Benign

Parotidectomy

Facial
Nerve

Neck
Dissection

Radiation

Chemotherapy

Superficial
Total -- deep

Preserve

N0

N0

N0

-- Do --

Yes
N0 / >

N0

N0

Post
operative

N0

T1 & T2
--- Do --Low Grade
M.E.Carcinoma
Acinic Cell
T1 & T2
High grade
malignancy

Total

-- do -- -- do --

87

Tumour Type

Parotidectomy

Facial
Nerve

Neck
Dissection

Radiation

Chemotherapy

Squamous Cell
Ca

Total

-- do
--

Yes

-- do --

Possible

T3 / Recurrent

-- do --

-- do
--

-- do --

-- do --

-- do --

Radical with
adjacent
structures

-- do
--

-- do --

-- do --

-- do --

T4

88

89

90

91

92

93

COMPLICATIONS:
RISK ASSOCIATED WITH GENRAL ANESTHESIA
WOUND INFECTION
BLEEDING
UNFAVOURABLE
SCARRING
RECURRENCE OF DISEASE
SALIVARY FISTULA & SIALOCELE
FREYS SYNDROME
INJURY TO NERVES
GREATER AURICULAR NERVE NUMBNESS OF
EAR
FACIAL NERVE
94

FREYS SYNDROME:
Copious sweating over parotidectomy site when
exposed to
Salivary stimulation or a simple erythematous blush
over parotid area
Abberent cross innervation between glandular
cholinergic parasympathetic nerves
To
Denervated cholinergic sympathetic nerves to
cutaneous sweat glands
Treatment :
Topical atropinoids
Tympanic neurectomy
Raising thick flaps
Interposing fascia, fat, or flaps over wound bed
Synthetic implants
Topical anticholinergics
95