SALIVARY GLAND ANATOMY

7/25/2019 SALIVARY GLAND ANATOMY

1/91


2/91

Sialolithiasis

Mucousretention/extravasation


3/91

Sialolithiasis results in a mechanicalobstuction of the salivary duct

Is the major cause of unilateral

diuse parotid or submandibulargland swelling2


4/91

scudier ! Mc"ur# $%$&'2( ((()

Marchal ! *ulgurerov $%$('2( (((2

Sialolithiasis remains the most fre+uentreason for submandibular gland

resection&


5/91

,he exact pathogenesis ofsialolithiasis remains un#nown-

,hought to form via.- an initial organic nidus thatprogressively grows by depositionof layers of inorganic and organicsubstances-

May eventually obstruct ow ofsaliva from the gland to the oralcavity-


6/91

0cute ductal obstruction mayoccur at meal time when saliva

producing is at its maximum1 theresultant swelling is sudden and

can be painful-


7/91

"radually reduction of theswelling can result but it

recurs repeatedly when ow isstimulated-

,his process may continue until

complete obstruction and/orinfection occurs-


8/91

ater hardness li#elihood3 .

Maybe.-

4ypercalcemia.in rats only 5erostomic meds

,obacco smo#ing1 positive correlation

Smo#ing has an increased cytotoxiceect on saliva1 decreases 6M7phagocytic ability and reduces salivaryproteins


9/91

"out is the only systemic

disease #nown to causesalivary calculi and these are

composed of uric acid-


10/91

8rganic9 often predominate in thecenter "lycoproteins

Mucopolysaccarides

:acteria;


11/91

Mostauthorities agree obstructive

phenomenon such as mucous plugsand sialoliths are most commonly foundin the SM" scudier et al)

=ustmann et al>

?ice@

8thers note that parotid glands aremost commonly aected2


12/91

Saliva more al#aline

4igher concentration of calcium andphosphate in the saliva

4igher mucus content

=onger duct

0nti'gravity ow


13/91

*espite a similar chemical ma#e'up1

A('B(C of SM" calculi are radio'

opa+ue@

&('A(C of parotid calculi areradiolucent@

)(C of SM" stones are multiple

D(C of 6arotid stones are multiple


14/91

6ainful swelling ED(CF

6ainless swelling E)(CF

6ain only E$2CF Sometimes described as recurrent

salivary

colic and spasmodic pains upon eating


15/91

4istory of swellings / change over time3 ,rismus3

6ain3 Gariation with meals3 :ilateral3 *ry mouth3 *ry eyes3

?ecent exposure to sic# contactsEmumpsF3

?adiation history3


16/91

0symmetry Eglands1 face1 nec#F

*iuse or focal enlargement

rythema extra'orally ,rismus

Medial displacement of structuresintraorally3

xamine external auditory canal E0


17/91

6alpate for cervical lymphadenopathy :imanual palpation of oor of mouth in

a posterior to anterior direction 4ave patient close mouth slightly ! relax

oral musculature to aid in detection

xamine for duct purulence

:imanual palpation of the gland EHrmor spongy/elasticF-


18/91

ective forintraductal

stones1 while.- intraglandular1

radiolucent or

small stonesmay be missed-


19/91


20/91


21/91

*isadvantages%

irradiation dose

pain with procedure infection1 dye reaction

push stone further

contraindicated in active infection-


22/91

seful to image the parenchyma ,BB is an artiHcial radioactive element

Eatomic K>)1 atomic weight BBF that isused as a tracer in imaging studies-

,BB is a radioisotope that decays andemits a gamma ray- 4alf life of D hours-

4elman ! Lox $BA@1 found that,echnitium'BB shares the 7a''


23/91

Some say ,BB is useful preoperativelyto determine if gland is functional-

4owever1 no evidence to suggest glandwonNt recover function after stoneremoved- 7ot advised for pre'opdecision ma#ing;


24/91

,2 weighted fast spin echo slides in

sagittal and axial planes- Golumetricreconstruction allows visualiOation ofducts

0*G% 7o dye1 no irradiation1 no pain

*IS%


25/91

0llows complete exploration of theductal system1 direct visualiOationof duct pathology

Success rate of JB&C2

*isadvantage% technicallychallenging1 trauma could result instenosis1 perforation


26/91

7one% antibiotics and anti'inammatories1 hoping forspontaneous stone passage-

Stone excision%

=ithotripsy

Interventional sialendoscopy

Simple removal E2(C recurrenceF@

"land excision


27/91

If patients *8 defer treatment1 theyneed to #now%

Stones will li#ely enlarge over time See# treatment early if infection

develops

Salivary gland massage and hyper'hydration when symptoms develop-


28/91

xternal lithotripsy

Stones are fragmented and expected topass spontaneously

,he remaining stone may be the idealnidus for recurrence

Interventional Sialendoscopy


29/91

Some say%

if a stone can be palpated thru the mouth1it can be removed trans'orally E,8F

8r if it can be visualiOed on a true centralocclusal radiograph1 it can be removed ,8-

Linally1 if it is no further than 2cm from

the punctum1 it can be removed ,8-


30/91

*eeper submandibular stones EP$&'2(Cof stonesF may best be removed viasialadenectomy-

Some surgeons say can still removetransorally1 but should be done viageneral anesthetic-

Lloor of mouth EL8MF opened opposite the

Hrst premolar1 duct dissected out1 lingualnerve identiHed-

*uct opened ! stone removed1 L8Mapproximated-


31/91

6reserves a functional gland

0voids nec# scar

6ossibly less time from wor# 7o overnight stay in hospital

0voids ris# to


32/91

0fter SM" excision1 )C cases haverecurrence via%

?etention of stones in intraductal portionor new formation in residual hartonQsduct

7o data regarding recurrence after

parotidectomy


33/91

Gery posterior stones Intra'glandular stones

SigniHcantly symptomatic patients

Lailedtransoral

approach


34/91

hile some believe that a gland withsialolithiasis is no longer functional1 arecent study on SM"s removed due tosialolithiasis found there was no correlation

between the degree of gland alteration andthe number of infectious episodes-

&(C of the glands were histopathologically

normal or close to normal 0 conservative approach to the gland/stone

seems to be justiHed


35/91

Sialolithiasis

Mucousretention/extravasation


36/91

Mucus is the exclusive secretoryproduct of the accessory minor salivaryglands and the most prominent productof the sublingual gland-

,he mechanism for mucus cavitydevelopment is extravasation or

retention


37/91

Mucoceles1 exclusive of theirritation Hbroma1 are mostcommon of the benign soft

tissue masses in the oral cavity- Muco% mucus 1 coele% cavity-

hen in the oral oor1 they arecalled ranula-


38/91

xtravasation is the lea#age of uid fromthe ducts or acini into the surroundingtissue-

Extra% outside1 vasa% vessel

?etention% narrowed ductal opening that

cannot ade+uately accommodate the exitof saliva produced1 leading to ductaldilation and surface swelling- =esscommon phenomenon


39/91


40/91

,he majority of the mucoceles resultfrom an extravasation of uid into thesurrounding tissue after traumaticbrea# in the continuity of their ducts-

=ac#s a true epithelial lining-


41/91

Is a term used formucoceles thatoccur in the oor ofthe mouth-

,he name is derivedform the word rana1because theswelling mayresemble the

translucentunderbelly of thefrog-


42/91

0lthough the source is usually thesublingual gland1

may also arise from the submandibularduct

or possibly the minor salivary glands inthe oor of the mouth-


43/91

6resents as a blue dome shapedswelling in the oor of mouth EL8MF-

,hey tend to be larger than mucoceles! can Hll the L8M ! elevate tongue-

=ocated lateral to the midline1 helpingto distinguish it from a midline dermoid

cyst-


44/91

8ccurs when spilled mucin dissectsthrough the mylohyoid muscle andproduces swelling in the nec#-


45/91

xcision with strict removal of any

projecting peripheral salivary glands 0void injury to other glands during

primary wound closure


46/91

MarsupialiOation has fallen into disfavordue to the excessive recurrence rate ofD('B(C

Sublingual gland removal via intraoralapproach


47/91

0cute bacterial sialdenitis


48/91

Sialadenitis represents inammationmainly involving the

acinoparenchyma of the gland-


49/91

0wareness of salivary gland infectionswas increased in $AA$ when 6resident"arHeld died from acute parotitisfollowing abdominal surgery andassociated systemic dehydration-


50/91

0cute infectionmore oftenaects themajor glands

than the minorglands$


51/91

$- ?etrograde contamination of thesalivary ducts and parenchymal tissuesby bacteria inhabiting the oral cavity-

2- Stasis of salivary ow through theducts and parenchyma promotes acutesuppurative infection-


52/91

More common in parotid gland- Suppurative parotitis1 surgical parotitis1

post'operative parotitis1 surgicalmumps1 and pyogenic parotitis-

,he etiologic factor most associatedwith this entity is the retrograde

infection from the mouth- 2(C cases are bilateral@


53/91

,he composition of parotid

secretions diers from those inother major glands-

6arotid is primarily serous1 the

others have a greater proportionof mucinous material-


54/91

Mucoid saliva contains elements thatprotect against bacterial infectionincluding lysoOymes ! Ig0 antibodiesEtherefore1 parotid has bacteriostatic activityF

Mucins contain sialic acid whichagglutinates bacteria and prevents itsadherence to host tissue-

SpeciHc glycoproteins in mucins bindepithelial cells competitively inhibitingbacterial attachment to these cells-


55/91

Minor role in formation of infections

StensenNs duct lies adjacent to the

maxillary mandibular molars andhartonNs near the tongue-

It is thought that the mobility of the tonguemay prevent salivary stasis in the area of

hartonQs that may reduce the rate ofinfections in SM"-


56/91

Systemic dehydration Esalivary stasisF


57/91

7eoplasms Epressure occlusion of ductF Sialectasis Esalivary duct dilationF

increases the ris# for retrograde

contamination- Is associated with cysticHbrosis and pneumoparotitis

xtremes of age 6oor oral hygiene


58/91

,here must be other factors at wor#.--

Sialolithiasiscan produce mechanicalobstruction of the duct resulting insalivary stasis and subse+uent glandinfection-


59/91

=ymphoma

0ctinomycoses


60/91

Sudden onset of erythematousswelling of the pre/post auricular

areas extend into the angle of themandible-

Is bilateral in 2(C-


61/91

6urulent saliva should be sent forculture-

Staphylococcus aureus is most common

Streptococcus pnemoniae and S-pyogenes

4aemophilus InuenOae also common


62/91

6arotitis is generally a clinical diagnosis 4owever1 in critically ill patients further

diagnostic evaluation may be re+uired levated white blood cell count Serum amylase generally within normal If no response to antibiotics in >A hrs can

perform M?I1


63/91

?everse the medical condition thatmay have contributed to formation

*iscontinue anti'sialogogues if possible arm compresses1 maximiOe 841 give

sialogogues Elemon dropsF

xternal salivary gland massage iftolerated


64/91

0ntibiotics; @(C of organisms produce :'lactamase

or penicillinase 7eed :'lactamase inhibitor li#e

0ugmentin or nasyn or secondgeneration cephalosporin


65/91

0fter >A hours the patient shouldrespond


66/91

=imited role for surgery hen a discrete abscess is identiHed1

surgical drainage is underta#en 0pproach is anteriorly based facial ap

with multiple superHcial radial incisionscreated in the parotid fascia parallel to

the facial nerve


67/91

*irect extension

0bscess ruptures into external auditorycanal and ,M have been reported

4ematogenous spread

,hrombophlebitis of theretromandibular or facial veins are rare

complications


68/91

Lascial capsule around parotid displayswea#ness on the deep surface of thegland adjacent to the loose areolar tissues

of the lateral pharyngeal wallE0chillesNheel of parotidF

xtension of an abscess into theparapharyngeal space may result inairway obstruction1 mediastinitis1 internal

jugular thrombosis and carotid arteryerosion


69/91

*ysfunction of one or more branches ofthe facial nerve is rare-

8ccurs secondary to perineuritis ordirect neural compression 9 butresolves with ade+uate treatment ofthe parotitis-

,hese patients need to be followed toensure resolution.-must rule out

,M8?-


70/91


71/91

8f importance in the wor#up.

,he clinician should loo# for a treatablepredisposing factor such as a calculusor a stricture-


72/91

Initial management should beconservative and includes the use ofsialogogues1 massage and antibiotics

for acute exacerbations-

Should conservative measures fail1consider removing the gland-


73/91

Mumps classically designates a viralparotitis caused by the paramyxovirus

4owever1 a broad range of viralpathogens have been identiHed ascauses of 0GI of the salivary glands-


74/91

*erived from the *anish wordTmompenU

Means mumbling1 the name given todescribe the characteristic muVedspeech that patients demonstratebecause of glandular inammation and

trismus-


75/91

0s opposed to bacterial sialadenitis1viral infections of the salivary glands

are SWS,MI< from the onset;


76/91

Mumps is a non'suppurative acutesialadenitis

Is endemic in the community andspread by airborne droplets


77/91

2') wee# incubation after exposureEthe virus multiplies in the ?I orparotid glandF

)'&day viremia

,hen localiOes to biologically activetissues li#e salivary glands1 germinal

tissues and the


78/91

8ccurs world wide and is highlycontagious

6rior to the widespread use of the eryl=ynn vaccine Elive attenuatedF1 caseswere clustered in epidemic fashion

Sporadic cases are observed today

li#ely resulting from non'paramyxoviralinfection1 failure of immunity or lac# ofvaccination


79/91


80/91

)(C experience prodromal symptomsprior to development of parotitis

4eadache1 myalgias1 anorexia1 malaise

8nset of salivary gland involvement isheralded by earache1 gland pain1dysphagia and trismus


81/91

"landular swelling Etense1 HrmF 6arotidgland involved fre+uently1 SM" ! S="can also be aected-

May displace ispilateral pinna @&C cases involve bilateral parotids1

may not begin bilaterally Ewithin $'&days may become bilateralF.-2&Cunilateral

=ow grade fever


82/91

=eu#ocytopenia1 with relativelymphocytosis

Increased serum amylase Enormal by 2') wee# of diseaseF

Giral serology essential to conHrm%


83/91

TSU or soluble antibodies directedagainst the nucleoprotein core of thevirus appear within the Hrst wee# of

infection1 pea# in 2 wee#s-

*isappear in A'B months and aretherefore associated with active or

recent infection


84/91

TGU1 or viral antibodies directed againstthe outer surface hemagglutinin1appear several wee#s after the S

antibodies and persist at low levels forabout & years following exposure-

G antibodies are associated with past

infection1 prior vaccination and the latestages of active infection


85/91

If the initial serology isnoncontributory1 then a non'paramyxovirus may be responsible for

the infection- :lood 4IG tests should also be obtained ,he mumps s#in test is not useful in

diagnosis an acute infection becausedermal hypersensitivity does notdevelop until ) or > wee#s followingexposure-


86/91

Supportive

Lluid

0nti'inammatories and analgesics


87/91

,he live attenuated vaccine becameavailable in $BD@

'Dyr


88/91

8rchitis1 testicular atrophy and sterilityin approximately 2(C of young men

8ophoritis in &C females 0septic meningitis in $(C 6ancreatitis in &C Sensorineural hearing loss X&C

sually permanent A(C cases are unilateral


89/91

$- McYuone1 S% 0cute viral and bacterial infections of thesalivary glands- 8to


90/91

D- Marchal L1 urt 0M1 *ulgeurov 61 :ec#er M et al-4istopathology of submandibular glands removed forsialolithiasis- 0nn 8to ?hinol-2(($9$$(1 >D>

@- ?ice *4- Salivary "land *isorders- Med


91/91

$2% rause "1 Meyers 0*- Managementof parotid swelling-

Documents

SALIVARY GLAND ANATOMY