Salivary

Treatment of
salivary neoplasm
J.Kavyasri, final year MBBS

MODERATOR: PROF.DR. T.KARUNAHARAN
The Salivary glands and ducts
01 02
SUBMANDIBULA
PAROTID GLAND
R
20 % of saliva, Stensen‘s duct. 70% of saliva, Wharton’s duct.
03 04
SUBLINGUAL
5% of saliva, bartholin‘s duct
ANATOMY OF SALIVARY GLAND
PAROTID GLAND
• largest of the salivary gland.
• situated below the acoustic meatus between the ramus of mandible and sternomastoid muscle.
• The deep cervical fascia splits to form a capsule

to enclose the gland. The superficial layer is thickened and adherent to the gland.
• It is deep to parotid fascia, superficial to masseter. So parotid swelling occupies below, behind,
in front of the ear lobule, obliterating the normal hollow below the ear lobule. When patient
opens the mouth,
Parts of the Parotid Gland

• Superficial part (80%)—lies over the posterior part of the ramus
of mandible.
• Deep part (20%)—lies behind the mandible and medial pterygoid
muscle; in relation to mastoid and styloid process.
Blood Supply
It is from external carotid artery; and venous
drainage is by external
jugular vein.
Nerve Supply
It is from autonomic nervous system,
parasympathetic is secretomotor
from auriculotemporal nerve, sympathetic is
vasomotor from plexus around the external
carotid artery
Lymphatic Drainage
It drains into parotid lymph glands which are
partly intraglandular and partly extraglandular
(preauricular and infraauricular). Mainly
intraglandular nodes are involved which
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later drains into deep cervical lymph glands.
Faciovenous Plane of Patey
• Faciovenous plane of Patey is of surgical importance.
Facial nerve is superficial to this plane which contains
retromandibular vein and posterior facial vein. External
carotid artery dividing into superficial temporal artery and
maxillary artery is deeper to venous plane
STENSEN’S DUCT
• Parotid (Stensen’s) duct is 2-3 mm in diameter, 5 cm in length.
• It emerges from anterior surface of the gland, runs over the
surface of the masseterpasses through the buccinator
muscle,and opens into the oral mucosa opposite to the crown
of upper second molar tooth
FACIAL NERVE
• It emerges from the stylomastoid foramen lying between external
auditory meatus and mastoid process. It passes around the neck of
the condyle of mandible and becomes superficial
• Division : temporofacial and cervicofacial branches which in turn divides into

many branches. Some of these may be interconnected as pes anserinus
(goose foot).
• Branches are – temporal , zygomatic upper
buccal and lower buccal,mandibular and cervical.
• While exiting the skull through stylomastoid foramen it gives posterior auricular nerve
and motor nerves to posterior belly of digastric and stylohyoid. Trunk is initially 1 cm
from posteromedial surface (extraglandular) and intraglandular
for 1 cm before giving divisions
SUBLINGUAL
SUBMANDIBULAR
GLAND
GLAND
• minor salivary glands one
on each side; It is a ‘J’ shaped salivary gland situated in the anterior
part of the digastric triangle.
• It is located in the anterior
aspect of the floor of the Parts
mouth in relation to Superficial part: Lies in submandibular triangle,
mucosa, mylohyoid muscle, superficial to mylohyoid and hyoglossus muscles,
body of the mandible near between the two bellies of digastric muscle.
mental symphysis. Deep part is in the floor of the mouth and deep to the
• Gland drains directly into mylohyoid.
mucosa or through a duct Submandibular (Wharton’s) duct (5 cm), emerges from
which drains into the anterior end of the deep part of the gland, enters the
submandibular duct. This floor of the mouth, on the summit of papilla beside the
frenulum of the tongue.
duct is called as Bartholin
duct.
PAROTIDECTOMY
Superficialparotidectomy:
Radical parotidectomy:
the removal of superficial
lobe
Total conservative Both lobes of parotid are
removed along with facial nerve,
parotidectomy: fat, fascia, muscles , lymph
nodes.
both lobes are removed with
preservation of facial nerve.
STEPS OF PAROTIDECTOMY
• Lazy ‘S’ incision—modified Blair's/Sistrunk's approach and raising the skin flaps
• Mobilisation of the gland
• Flap is reflected in front just up to anterior margin of the parotid;

never beyond. After identification of sternocleidomastoid great
auricular nerve is identified and can be sacrificed
• Location of stylomastoid branch of posterior auricular artery

is anterior to facial nerve trunk which enters the stylomastoid foramen.
Thrust the mosquito haemostat 5 mm in front of facial nerve; open the blades for 5 mm; lift
the blades for 5 mm.
IDENTIFICATION OF FACIAL NERVE
Facial nerve is 1 cm deep and below the tip of the inferior portion
of the cartilaginous canal—Conley’s point
By nerve stimulator, tympanic suture.
It is inferomedial to tragal point ,
Deep to digastric muscle and tympanic plate
Nerve is just lateral to the styloid process

Tracing branch from distal to proximal
Dissection of the gland off the facial nerve using bipolar cautery.
Removal of parotid—superficial/both.
Distilled water (hypertonic) irrigation to kill spilled tumour cells. Haemostasis
and closure with a suction drain.
COMPLICATIONS OF PAROTIDECTOMY
Salivary fistula &

Haemorrhoge 01 02
Flap necrosis
Facial
nerve
INJUR
Y
Sialocele
Frey’s syndrome Greater auricular
03 04 nerve injury
FACIAL NEREVE INJURY
Loss of forehead wrinkling, wide palpebral fissure,

bell’s phenomenon
Epiphora, inability to close the eyelid,obliteration of

nasolabial fold
Drooping of angle of mouth, difficulty in blowing and

clenching
TREATMENT
• Nerve grafting using greater auricular nerve, sural nerve, lateral cutaneous
nerve of thigh or hypoglossal nerve.
• Suspension of angle of mouth to zygomatic bone using temporal fascia sling.
• Lateral tarsorrhaphy—to prevent corneal ulceration.
• Medial canthus reconstruction—to reduce epiphora.
• Cross-facial nerve transplantation from opposite side using its
insignificant branches.
• Dynamic neurovascular muscle graft.
• Upper lid gold weights to protect cornea.
FREY’S SYNDROME
.
• It is due to injury to the auriculotemporal nerve.
• Auriculotemporal nerve has got two branches. Auricular branch
supplies external acoustic meatus, surface of tympanic membrane, skin of auricle
above external acoustic meatus.
• Temporal branch supplies hairy skin of the temple. Sweating and
hyperaesthesia occurs in this area of skin
postganglionic parasympathetic fibres from the otic ganglion become united to
sympathetic nerves from the superior cervical ganglion (Pseudosynapsis). There is
inappropriate regeneration of the damaged parasympathetic autonomic nerve
fibres to the overlying skin
CLINICAL FEATURES:
• Flushing, sweating, erythema, pain and hyperaesthesia in the skin

over the face innervated by the auriculotemporal nerve.
• Involved skin is painted with iodine and dried. Dry starch applied
over this area will become blue due to more sweat in the area —Minor's Starch
iodine test
TREATMENT
• Initially conservative and reassurance.. Antiperspirants, anticholinergics like
scopolamine 3%, glycopyrrolate 1%, methyl sulfate, radiation 50 Gy are used.
• Jacobsen neurectomy (tympanic)
• Dermal/fat graft.
THANKS!
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Treatment of

J.Kavyasri, final year MBBS

• largest of the salivary gland.

• The deep cervical fascia splits to form a capsule

Parts of the Parotid Gland

• Division : temporofacial and cervicofacial branches which in turn divides into

• Mobilisation of the gland

• Flap is reflected in front just up to anterior margin of the parotid;

• Location of stylomastoid branch of posterior auricular artery

Nerve is just lateral to the styloid process

Salivary fistula &

Loss of forehead wrinkling, wide palpebral fissure,

Epiphora, inability to close the eyelid,obliteration of

Drooping of angle of mouth, difficulty in blowing and

• Flushing, sweating, erythema, pain and hyperaesthesia in the skin

CREDITS: This presentation template was created by Slidesgo,

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