1. Diseases of
salivary glands
Instructor – Dr. Jesus
George
1

2. Introduction
 The salivary glands classified as major&
minorglands
 Major glands are paired glands they are
 Parotid glands
 Submandibular glands
 Sublingual glands
 The numerous minor salivary glands , widely
distributed in the oral cavity
 Salivary gland secretion contain water,
electrolytes , urea , ammonia , glucose , fats
&proteins
2

3. Parotid gland
 Largest salivary gland
 Pyramidal in shape
 Two lobes superficial , & deep connected by
an isthmus at posterior part of gland
 Apex is toward angle of mandible
 Base at the external acoustic meatus
 Anteriorly gland extends up to buccal pad of
fat
 Posteriorly encircles posterior border of
mandible
 Parotid gland secretion is serous in nature
3

4. Parotid duct (Stenson's duct )
 Stenson`s duct emerges at anterior part of
gland
 Stenson`s duct opening is seen as a papilla in
the buccal mucosa opposite maxillary second
molar
4

5. Submandibulargland
 The gland is located submandibular space
 Extending inferiorly up to digastric muscle
 Superiorly mylohyoid muscle
 Posteriorly up to angle of mandible
 Anteriorly mid portion of body of the mandible
 Submandibular gland secretion is mixed
5

6. Submandibularduct (Wharton's
duct)
 The duct starts from deep part of gland
 Turns sharply at the posterior border of
mylohyoid muscle anteriorly & superiorly ,
crosses hyoglossus muscle
6

7. Sublingual gland
 This gland is located in sublingual space it is
present in association with sublingual fold
below tongue , & divided into anterior &
posterior part
 Sublingual gland secretes both serous &
mucous
 Bartholin’ s duct
 The ducts of anterior part may join to form a
large main duct called Bartholin’ s duct
7

8. Minorsalivary glands
 More than 800 minor salivary glands may be
present in oral cavity
 Secrete mucous secretions
8

9. Functions of saliva
 Digestive function
 Protective function
 Cleansing
 Lubrication
 Antibacterial action
9

10. Classification of salivary gland
diseases
 Salivary gland dysfunction
 Xerostomia
 Sialorrhea
 Developmental
 Aplasia - absenceof thegland
 Atresia - absenceof theduct
 Aberrancy- ectopic gland
10

11. Cont.
 Enlargement of the gland
 Inflammatory
 Viral ; mumps
 Bacterial
 Non– inflammatory
 Autoimmune; Sjogren’s syndrome
 Alcoholic cirrhosis
 Diabetes mellitus
 Sialolithiasis
11

12. CONT.
 Cysts
 Retentioncysts
 Extravasationcyst
 Ranula
 Tumours of salivary glands
 Benign tumours
 Pleomorphic adenoma
 Warthin’s tumour
12

13. CONT.
 Malignant tumours
 Mucoepidermoid carcinoma
 Acinic cell carcinoma
 Adenoid cystic carcinoma
 Necrotizing sialometaplasia
13

14. Xerostomia
 Xerostomia is a subjective sensation of a dry
mouth
 It affects women more than men , are
commonly in older people
 Antihistamines , decongestants ,
antidepressants , antipsychotics,
antihypertensives, & anticholinergics are
known to cause xerostomia
 Other cause of xerostomia -- salivary gland
aplasia, aging , excessive smoking , mouth
breathing , local radiation therapy , Sjogren’s
syndrome & HIV infection
14

15. Cont.
 Clinical features
 Dry mouth with foamy , thick , & ropy saliva
 Gloves stick to the mucosa
 Difficulty in mastication & swallowing
 More chance for candidiasis & caries
 Treatment
 Removal of the cause
 Maintenance oral hygiene
 Use of sialagogues
15

16. Cont.
 Systemic pylocarpine 5- 10 mg 3-4 times daily
 Frequent dental visits
 Topical fluoride application
16

17. Sialorrhoea
 Sialorrhoea is excessive salivation
 Minor sialorrhea can be seen due to local
irritation like aphthous ulcers or ill- fitting
dentures
 Profuse salivation is seen in rabies, heavy
metal poisoning, gastro esophageal reflux
disease or after certain medication like lithium
& cholinergic agonists
 Mentally retarded children also excessive
salivation – not by excessive production of
saliva
 Treatment
 Removal of the cause
17

18. Cont.
 Anticholinergic medication
 Submandibular gland resection
 Parotid duct ligation.
18

19. Sialadenitis
 Inflammation of the salivary glands is known
as sialadenitis
 Causes
 Viral infections
 Bacterial infections
 Allergic reactions
 Systemic diseases
19

20. Mumps
 It is also called as epidemic parotitis.
 It is caused by paramyxo virus and affects
major salivary glands, especially the
parotid salivary gland.
 Clinical Features:
 The mumps virus can be transmitted through
urine, saliva or respiratory droplets.
 Incubation period-16 to 18 days.
20

21. Cont.
 Patients are contagious 1 day before & 14
days after the resolution
 Usually subclinical
 If symptomatic prodromal symptoms of Low-
grade fever, Headache, malaise & Myalgia
 Discomfort & swelling over the lower ½ of
external ear down to posterior & inferior
border of mandible
 Either one or both the parotid gland are
enlarged and become tender.
21

22. Cont.
 Enlargement & pain are maximum in 2-3 days
 Chewing movements or saliva stimulating
foods increases pain
 Enlargement begins on one side & then
extends to other side
 There many also be and edema & erythema
involving the ductal orifice.
 If sublingual gland is involved – bilateral
enlargement of floor of mouth
22

23. Cont.
 Complications
 Pancreatitis
 Orchitis
 Oophoritis
 Meningio encephalitis
 Diagnosis:
 Urine, saliva & cerebrospinal fluid for culture.
23

24. Cont.
 Treatment:
 Analgesics and antipyretics
 Bed rest
 Avoidance of sour foods
 Prior vaccination
24

25. Bacterial infection
 Bacterial infection can inflammation of major
salivary glands
 Bacterial sialadenitis affects parotid gland
more commonly
 Submandibular glands are rarely affected
25

26. Acute bacterial sialadenitis
 Organisms - staph ;aureus , strep ; pyogenes,
strep; viridans etc
 Some drugs like tranquilizers; antiparkinson
drug ; diuretics; & antihistamines drugs etc
decrease salivary flow with increased chance
of infection of salivary glands
 Clinical features
 Sudden onset of pain at angle of the jaw
which is unilateral
26

27. Cont.
 Affected gland is enlarged & tender &
extremely painful
 Inflammatory swelling is very tense & does not
show much fluctuation
 Skin is warm & red
 Associated fever & trismus may be there
 Purulent discharge from the affected duct
orifice
 Histopathologic features
 Accumulation of neutrophils is observed
with in ductal system & acini
27

28. Cont.
 Treatment
 Antibiotics
 Hydrating the pt
 Stimulate the salivation by chewing
sialagogues
 Improve oral hygiene by debridement &
irrigation
 Surgical drainage if abscess is there
28

29. Chronic bacterial siladenitis
 It may be idiopathic or with factors like
 Duct obstruction ,
 Congenital stenosis,
 Sjogren ’s syndrome
 The microorganisms may be strep; viridans, e-
coli
 Clinical features
 Unilateral periodic pain & swelling at the angle
of jaw usually during mealtime
 Gland may undergo atrophy , which results in
decreased salivary flow
29

30. Cont.
 Histopathologic features
 Patchy infiltration of salivary parenchyma
by lympocytes & plasma cells
 Atrophy of acini & ductal dialatation &
sometimes fibrosis
 Sialography – ductal dialatation proximal to
area of obstruction
 Treatment
 Antibiotics
30

31. Cont.
 Intra ductal infusion of erythromycin or
tetracycline
 Excision of the gland
31

32. 32

33. Sjogren syndrome
 Characterized by dry eyes , xerostomia &
rheumatoid arthritis
 Clinical features
 Occurs predominantly in women
 Dry eyes & dry mouth
 Pain & burning sensation
 Red & tender mucosa with Ulceration
 Difficulty in swallowing
 Altered taste sensation
 Denture sore mouth
33

34. Cont.
 Angular cheilitis
 There may have diffuse firm enlargement of
major salivary glands usually bilateral
 Sialography- demonstrates cavitary defects
are filled with radiopaque contrast media
producing ‘ branchless fruit laden tree’ or
“cherry blossom appearance”
 Histopathologic features
 Lymphocytic infiltration with destruction of
acinar cells
34

35. Cont.
 Treatment
 Xerostomia - artificial saliva,sugarless
gums,pilocarpine
 Flouride application to prevent caries
35

36. 36

37. Sialadenosis
 It is non- inflammatory , non - neoplastic
swelling of the salivary gland
 Sialadenosis can occur in the following
conditions;
 Hormonal disorders(pregnancy, hypothyroidism)
 Diabetes mellitus
 Alcoholic cirrhosis
 Malnutrition
 Caused by dysregulation of autonomic
innervation of salivary acini causing aberrent
intracellular secretory cycle leading to
excessive secretion of secretory granules
37

38. Cont.
 Clinical features
 Enlargement is usually painless
 Usually bilateral
 More common in women
 Commonly affects parotid
 Histopathologic features
 Hypertrophy of acinar cells
 Nuclei are displaced to the base
 Cytoplasm is engorged with zymogen
granules
38

39. Cont.
 In DM & alcoholism – acinar atrophy & fatty
infiltration
 Treatment
 Control underlying cause
 Pilocarpine
39

40. Sialolithiasis
 Sialolithiasis is the formation of sialolith
( salivary calculi, salivary stone ) in the salivary
duct or gland resulting in the obstruction of the
salivary flow
 Sialolith
 Sialolith is a calcified mass with laminated
layers of inorganic material from crystallization
of salivary solutes
 The sialolith is yellowish white in colour ;
 Single or multiple, may be round & ovoid or
elongated having size of 2cm or more
diameter
40

41. Cont.
 The minerals are various forms of calcium
phosphate like hydroxyapatite, octacalcium
phosphate etc
 Calcium & phosphorus ions are deposited on
the organic nidus, may be desquamated
epithelial cell, bacteria, foreign particle or
product of bacterial decomposition
 It may be related to sialadenitis or ductal
obstruction
 Clinical features
 Commonly seen in middle -age persons
41

42. 42

43. Cont.
 More common in submandibular salivary ductal
system
 Pain & swelling during & after eating food
 Stone can be palpated if it is in the peripheral
aspect of the duct
 Minor salivary stones are seen as
asymptomayic hard nodule commonly in upper
lip
 Histopathologic features
 Sialoliths appear as round , & oval calcified
mass exhibits concentric laminations surround
a nidus of amorphous debris43

44. Cont.
 Investigations
 Radiographs –PA view , lateral oblique or
occlusal view – shows radiopaque mass
 Sialography
 Treatment
 Smaller sialoliths, are located peripherally
near ductal opening may be removed by
manipulation called milking the gland
 Larger sialoliths are surgically removed
44

45. Cont.
 Stones which are not impacted , may be
extracted through the intubation of the duct
with fine soft plastic catheter& application of
the suction to the tube
 Piezoelectric shock wave lithotripsy
 Multiple stones or stone in gland require
removal of the gland
 Transoral sialolithotomyof thesubmandibular
duct
 Local anaesthesia
 Position of the stone is located by x-rays &
palpation
45

46. Cont.
 Suture is placed behind the stone
 Tongue is lifted & held with help of a gauze
 Incision is made in the mucosa parallel to the duct
 Duct is located by blunt dissection
 Longitudinal incision is made over the stone
 Stone removed using small forceps, in case the
stone is large, it is crushed with help of the
forceps
 Cannula may be passed to aspirate the pieces of
stone, mucin etc
 Sutures are placed at the level of the mucosa
46

47. Mucocele
 Lower lip is commonly affected
 Other common sites are buccal mucosa,
ventral tongue, floor of mouth
 It can be superficial or deep
 Superficial – elevated well circumscribed
vesicle with bluish hue
 Deep – nodule with no change in color
 Cystic contents – thick mucous material
 Usually covered by mucous membrane
 There may have periodic rupture of the
swelling releasing the contents47

48. 48

49. Cont.
 After rupture it may leave shallow painful
ulcers
 Some lesions resolve by itself
 Histopathologic features
 Area of spilled mucin surrounded by granulation
tissue
 Adjacent minor salivary glands contain c/c
inflammatory infiltrate
 Treated by excision along with adjacent minor
salivary glands to prevent recurrence
49

50. Salivary duct cyst
 Mucus retention cyst or sialocyst
 Epithelium lined cavity that arises from salivary
gland tissue
 True cyst
 May be caused by ductal dilatation or
secondary to ductal obstruction
 It can be seen in major or minor salivary
glands
 Cysts of major glands are common in parotid
gland
 Intraoral cyst are common in buccal mucosa,
floor of mouth & lips
50

51. Cont.
 They are soft, fluctuant, asymptomatic swelling
& may appear bluish depending on the depth
 Histopathologically – cyst may be lined by
cuboidal, columnar or squamous epithelium
surrounding the mucoid secretion in lumen
 Treated by local excision for minor salivary
gland ducts
 For major salivary glands total or partial
removal of gland can be done
 Sialgogues can stimulate salivation & prevent
accumulation of mucus
51

52. 52

53. Ranula
 Extravasation cyst usually arises from ducts of
sublingual gland
 Bluish, dome shaped, fluctuant swelling in
floor of mouth
 May enlarge raise the tongue
 Usually seen lateral to midline
 May extend to the neck behind the posterior
border of mylohyoid (plunging ranula)
 Histopathologically similar to mucocele
 Treated by marsupialization or removal of the
feeding sublingual gland53

54. 54

55. Pleomorphic adenoma
 It can affect both major & minor salivary gland
 It commonly affects the parotid gland
 Clinical features
 More commonly in females
 Small painless nodule at the angle of
mandible or beneath the ear lobe
 Well circumscribed , encapsulated , firm in
consistency & may show area of cystic
degeneration
 Difficulties in mastication & talking
 Initially tumor is movable but later becomes55

56. Cont.
 If deep lobe is affected , a swelling in the
lateral pharyngeal wall or soft palate
 Minor salivary gland involvement is common in
palate & lip as smooth surfaced dome shaped
swelling
 Histopathologic features
 Well - circumscribed , encapsulated tumor
 Tumor is composed of a mixture of glandular
epithelium & myoepithlial cells with in a
mesenchyme like background may be myxoid
or chondromatous or hyalinized56

57. 57

58. Cont.
 Treatment - surgical excision
58

59. Warthin tumor
 Papillary cystadenoma lymphamatosum
 Affects the parotid glands
 Males are affected more
 Clinical features
 Firm or fluctuant, non- tender , circumscrided
mass in the region of angle or ramus of the
mandible or beneath ear lobe
 Common in the tail of the gland
 Both side parotid gland affected
59

60. 60

61. Cont.
 Histopathologic features
 Tumour composed of mixture of ductal
epithelium & lymphoid tissue
 Treatment
 Surgical excision
61

62. Mucoepidermoid carcinoma
 The low grade tumour behaves almost like a
benign tumour with very good prognosis
 High grade tumour behaves very aggressively
 It occurs with equal distribution between
males& females
 Clinical features
 More common in parotid gland
 It may grow slowly or rapidly
 Painless swelling
 Ulceration
62

63. Cont.
 Facial paralysis
 Minor salivary gland tumors are common in
palate & may have bluish hue
 Local destruction & metastasis to regional
lymph nodes & distant metastasis to the lung
 Histopathologic features
 Mucus producing cells & squamous cells
 High grade tumors have cellular atypia

63

64. 64

65. Cont.
 Treatment
 Surgical excision
 For minor salivary glands excision with
surrounding normal tissues
 For tumors with metastasis radical resection
with radiation
65

66. Acinic cell carcinoma
 A low grade malignancy
 Clinical features
 Commonly occurs in parotid gland
 Common in females
 Usually asymptomatic
 Commonly affects serous acini
 In minor salivary glands it is common in buccal
mucosa, lip & palate
 It may be a slow growing swelling
 Sometimes pain, tenderness may be there
66

67. 67

68. Cont.
 Histopathologic features
 Acinar cell has abundant granular basophilic
cytoplasm & round, darkly stained eccentric
nucleus
 Treatment
 Tumour confined to the superficial lobe is
treated by lobectomy
 Tumour involving deep lobe - parotidectomy
 Radiotherapy for severe cases
68

69. Adenoid cystic carcinoma
 It is also called cylindroma
 Clinical features
 Slow growing swelling
 Commonly occurs in palatal minor salivary
glands
 Commonly occurs in middle aged individuals
 Constant , low grade, dull aching pain
 Facial nerve paralysis in parotid tumours
 Histopathologic features
 Islands of basaloid epithelial cells that contain
multiple cylindric , cyst like spaces
69

70. 70

71. Cont.
 Perinueral invasion
 Treatment
 Surgical excision
71

72. Necrotizing sialometaplasia
 It is a locally destructive inflammatory lesion
affecting minor salivary glands
 Cause is ischemia of salivary tissues
 Clinical features
 Commonly occurs in men
 Minor salivary glands of the palate, lip or
retromolar pad affected
 The lesion occurs as a swelling with
paresthesia then it sloughs leaving large ulcer
or ulcerated nodule
 Edge of lesion presents with an inflammatory72

73. 73

74. Cont.
 Histopathologic features
 Acinar necrosis
 Squamous metaplasia of salivary ducts
 Treatment
 Debridement by hydrogen peroxide or saline
 Application of gentian violet
 The lesion is self - limiting one & heals in 6 to
8 weeks
74

75. Sialography
 It is a specialized radiographic procedure
performed for detection of disorders of major
salivary glands
 Mercury is used as contrast agent
 It involves cannulation & filling with a
radiopaque or contrast agent to make them
visible on a radiograph
 Indications
 Detection of calculi or foreign bodies
75

76. Cont.
 Determination of the extent of destruction of
salivary gland tissue secondary to obstruction
such as calculi or foreign bodies
 Detection of fistulae , diverticuli & strictures
 Detection & diagnosis of recurrent swelling &
Inflammatory processes
 Demonstration of tumour ; its size location &
origin
 Selection of the site for biopsy
76

77. Cont.
 Contraindications
 Pt with allergy or hypersensitivity to contrast
media
 Acute inflammation of the salivary glands
 Pt scheduled for thyroid function test
 Technique
 Identification of the location of duct orifices
 Exploration of the duct with lacrimal probe
 Cannulation of the ducts
 Introduction of the radiographic dye
77

78. Cont.
 Radiographic projections
 Lateral oblique projection
 Lateral projection
 Occlusal projection
 Antero- posterior projection
 OPG projection
78

79. Surgical management
 Superficial parotidectomy
 Complete excision of parotid gland
 Biopsy orexcision of submandibulargland
79

80. Superficial parotidectomy
 Indications
 Tumour ; common is pleomorphic adenoma
 Massive enlargement secondary to
 Sjogren’s syndrome
 Calculus in the hilum of gland - calculus is
removed without removal of the gland
 Chronic infection
80

81. Cont.
 Approaches
 Preauricular
 Submandibular
 Combination of the two
 Preauricularincision
 Incision is taken in the skin
 Platysma & superficial fascia dissected
 Duct is identified at anterior border of gland
81

82. Cont.
 Duct is followed backward through substance
of gland until calculus identified & recovered
 Fascial sheath encasing the gland is closed
completely
 Wound is closed in layers
 Pressure dressing given
82

83. Complete excision of parotid
gland
 In this procedure facial nerve preservation is
difficult so this should be explained to the pt
 Y-shaped incision is planned, starting from
the superior attachment of the pinna
downward & anteriorly toward angle of the
mandible & anteriorly , forward till hyoid bone
 The second arm of incision is made posterior
to the pinna
 Ear lobe is retracted upward & skin flap is
developed on the cheek side of the incision
83

84. Cont.
 Superficial lobe is freed from its attachments
 Stenson’s duct is located , ligated & cut
 Deep lobe is approached
 Ligation of external carotid artery & posterior
facial vein is carried out
 Facial nerve is then carefully elevated from the
deep portion
 Deep portion is gently dissected out of the
retromandibular space
 Wound is closed in layers
84

85. Excision of submandibular
gland
 An incision , 4to5 cm in length , is taken in the
skin in the submandibular region
 Incision is placed in, or parallel to the skin
creases , about 2cm below submandibular
border
 Wound is deepened through platysma & deep
fascia
 Branches of facial nerve in the field are
identified , mobilized & retracted
 Facial vein is identified & ligated
85

86. Cont.
 Lower pole of the gland is exposed, grasped
with tissue holding forceps
 Facial artery is ligated & divided
 Gland is separated from lower border of
mandible
 Lingual nerve is dissected
 Ligature is passed anterior to ductal pathosis
 Second ligature is passed posterior to the first
one , but still anterior to the ductal pathosis&
duct is sectioned between the ligatures
86

87. Cont.
 Deep part of the gland is excised
 Wound sutured in layers
87

88. Complications of surgery of
salivary glands
 Damage to lingual nerve
 Damage to Wharton's duct
 Damage to Auriculotemporal nerve
 Facial nerve paralysis
88