salivary glands introduction and anatomy

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2. Diagnosis and Diagnosis and
management of salivary management of salivary
gland disordersgland disorders

3. Salivary GlandsSalivary Glands
Salivary Glands secreat the saliva, which Salivary Glands secreat the saliva, which
lubricate the oral cavity to help in lubricate the oral cavity to help in
mastication, degulation and speech, mastication, degulation and speech,
prevents its from infection and caries.prevents its from infection and caries.

4. Embryology of salivary GlandsEmbryology of salivary Glands

Salivary glands develop from the embryonic Salivary glands develop from the embryonic
oral cavity as buds of epithelium into under oral cavity as buds of epithelium into under
lying mesenchymal tissue.lying mesenchymal tissue.

This epithelium ingrowths branch to form This epithelium ingrowths branch to form
primitive ductal system that eventually primitive ductal system that eventually
canalized to provide for drainage of salivary canalized to provide for drainage of salivary
secretion.secretion.

The minor SG begins to develop around the The minor SG begins to develop around the
fortieth day in utero, where as major SG fortieth day in utero, where as major SG
about the thirty-fifth day in utero.about the thirty-fifth day in utero.

5. 
At around the 7At around the 7
thth
or 8 or 8
thth
month in utero, month in utero,
secretary cells called acini begin to secretary cells called acini begin to
develop around the ductal system.develop around the ductal system.

The acini cells classified into:The acini cells classified into:

Serous: Serous:
produce thin watery secretionproduce thin watery secretion

Mucous: Mucous:
produce thick, viscous secretionproduce thick, viscous secretion

6. Salivary glands are divided in two Salivary glands are divided in two
group:group:

Major Salivary glandsMajor Salivary glands

Minor Salivary glandsMinor Salivary glands

7. Major Salivary glandsMajor Salivary glands
Major SG are paired structures Major SG are paired structures

Parotid GlandParotid Gland

Submandibular GlandSubmandibular Gland

Sublingual glandSublingual gland

8. Minor Salivary glandsMinor Salivary glands

800-1000 in no.800-1000 in no.
Found thorough out the oral cavity with exception of, Found thorough out the oral cavity with exception of,
anterior third of the hard palate, attached gingiva, anterior third of the hard palate, attached gingiva,
and dorsal surface of anterior third of tongue.and dorsal surface of anterior third of tongue.
Refered as, Refered as,
Labial,Buccal,Palatine,Tonsillar,RetromolarLabial,Buccal,Palatine,Tonsillar,Retromolar
lingual glands…..lingual glands…..

9. Parotid GlandParotid Gland
Largest salivary gland.Largest salivary gland.
Wedge shapeWedge shape
Superficail to the posterior Superficail to the posterior
aspect of masseter aspect of masseter
muscle.muscle.
Peripheral portion extend Peripheral portion extend
to the mastoide process, to the mastoide process,
along the anterior aspect along the anterior aspect
of sternocleidomastoide of sternocleidomastoide
muscle.muscle.
Small duct coalsce to form Small duct coalsce to form
stentson’s duct, about 1-stentson’s duct, about 1-
3mm in diameter and 3mm in diameter and
6cm in length.6cm in length.

10. Submandibular GlandSubmandibular Gland

The posterior-The posterior-
superior portion of superior portion of
the gland curves up the gland curves up
around the posterior around the posterior
border of the border of the
mylohyoid and gives mylohyoid and gives
rise to Wharton’s rise to Wharton’s
duct.duct.

11. Submandibular glandSubmandibular gland

2-4mm in diameter & about 5cm in 2-4mm in diameter & about 5cm in
length.length.

It opens into the floor of the mouth thru It opens into the floor of the mouth thru
a punctum. a punctum.

The punctum is a constricted portion of The punctum is a constricted portion of
the duct to limit retrograde flow of the duct to limit retrograde flow of
bacteria-laden oral fluids.bacteria-laden oral fluids.

12. Sublingual GlandSublingual Gland
Lie on the superior surface of the mylohyoid Lie on the superior surface of the mylohyoid
muscle and are separated from the oral muscle and are separated from the oral
cavity by a thin layer of mucosa.cavity by a thin layer of mucosa.
The ducts of the sublingual glands are The ducts of the sublingual glands are
called Bartholin’s ducts. called Bartholin’s ducts.

In most cases, Bartholin’s ducts consists of In most cases, Bartholin’s ducts consists of
8-20 smaller ducts of Rivinus. These ducts 8-20 smaller ducts of Rivinus. These ducts
are short and small in diameter. are short and small in diameter.

13. Salivary Gland produce 1000-1500 ml Salivary Gland produce 1000-1500 ml
saliva/day.saliva/day.
Sabmandibular 70%Sabmandibular 70%
Parotid 25%Parotid 25%
Sublingual 3%Sublingual 3%
Minor SG Traces amountMinor SG Traces amount

14. DIAGNOSTIC MODALITIESDIAGNOSTIC MODALITIES
 1.History and clinical examination1.History and clinical examination
 2.Salivary Gland radiology:2.Salivary Gland radiology:
i. Plain film radiographyi. Plain film radiography
ii. Sialographyii. Sialography
iii. CT,MRI & Ultrasoundiii. CT,MRI & Ultrasound
iv. Salivary scintographyiv. Salivary scintography
 3.Salivary Gland Endoscopy ( Sialoendoscopy )3.Salivary Gland Endoscopy ( Sialoendoscopy )

4.Sialochemistry4.Sialochemistry
 5.Fine-Needle Aspiration Biopsy5.Fine-Needle Aspiration Biopsy
 6. Salivary Gland Biopsy6. Salivary Gland Biopsy

15. Plain radiographyPlain radiography
Use to detect the radiopaque calculi.Use to detect the radiopaque calculi.

Occlusal View Occlusal View

Panaromic RadiographPanaromic Radiograph

Periapical ViewPeriapical View

16. Occlusal ViewOcclusal View

17. Panaromic View ( OPG )Panaromic View ( OPG )

18. Periapical ViewPeriapical View

19. SialographySialography
A radiographic examination of the A radiographic examination of the
salivary salivary
glands and ducts usingglands and ducts using
contrast media.contrast media.

20. SialographySialography

Gold standard specialized radiogarphic Gold standard specialized radiogarphic
technique.technique.

Indicated to detetect stones, Indicated to detetect stones,
radiopaque,80-85% radiolucent 15-20%.radiopaque,80-85% radiolucent 15-20%.

Inflammation of a duct or gland.Inflammation of a duct or gland.

May be used as a therapeutic May be used as a therapeutic
maneuver.maneuver.

21. ContraindicationsContraindications

Severe infection of a glandSevere infection of a gland

Known allergies to contrast mediaKnown allergies to contrast media

22. SialographySialography
TechniqueTechnique

Salaviray duct cannulated with plastic or Salaviray duct cannulated with plastic or
metal catheter.metal catheter.

Radiographic contrast medium, high Radiographic contrast medium, high
concentration of iodine ( 25-40 % ), 0.5 concentration of iodine ( 25-40 % ), 0.5
to 1 ml injected into the duct.to 1 ml injected into the duct.
 Two type contrast medium :Two type contrast medium :
Water-soluble Water-soluble
Oil-basedOil-based

24. Phases of SialogramPhases of Sialogram
Depend upon the time at which the Depend upon the time at which the
radiograph is obtained after the radiograph is obtained after the
injection of contrast medium.injection of contrast medium.
1. Ductal phase. 1. Ductal phase.
2. Acinar phase.2. Acinar phase.
3. Evacuation phase.3. Evacuation phase.

25. 1. Ductal phase1. Ductal phase

26. 2. Acinar phase2. Acinar phase

27. 3. Evacuated phase3. Evacuated phase

Asses normal secretory clearences Asses normal secretory clearences
function of the gland to determine the function of the gland to determine the
avidence of retentionavidence of retention

The retention of contrast in the gland The retention of contrast in the gland
or ductal system beyound 5 min is or ductal system beyound 5 min is
considerd abnormal.considerd abnormal.

29. SUBMANDIBULAR GLANDSUBMANDIBULAR GLAND

31. iii. CT Scaning,iii. CT Scaning,
MRIMRI
UltrasoundUltrasound

32. iv.Salivary scintographyiv.Salivary scintography
( radioactive isotope scaninig )( radioactive isotope scaninig )

SC is a use of nuclear imaging in the form of radioactive SC is a use of nuclear imaging in the form of radioactive
isotopes.isotopes.

Allows the thorough evaluation of the salivary gland Allows the thorough evaluation of the salivary gland
perenchyma,with respect to the presence of mass lesion perenchyma,with respect to the presence of mass lesion
and function of gland.and function of gland.

This study uses a radioactive isotopes This study uses a radioactive isotopes
( Technetium TC 99m ) injected intravenously.( Technetium TC 99m ) injected intravenously.

Distributed thorough out the body, including salivary Distributed thorough out the body, including salivary
gland.gland.

Major limitation, aside from radiation exposure Major limitation, aside from radiation exposure
obtained, poor resulation images.obtained, poor resulation images.

Acutly inflamed gland Increase uptake of isotopeAcutly inflamed gland Increase uptake of isotope

Choronically inflamed gland Decraese uptake of isotopeChoronically inflamed gland Decraese uptake of isotope

33. 3. Salivary Gland Endoscopy3. Salivary Gland Endoscopy
( Sialoendoscopy )( Sialoendoscopy )

34. 5. Sialochemistry5. Sialochemistry

An examination of the electrolyte An examination of the electrolyte
composition of the saliva may indicate a composition of the saliva may indicate a
variety of salivary gland disorders.variety of salivary gland disorders.
Certain changes in the concentration of Certain changes in the concentration of
these electrolytes are seen in specific these electrolytes are seen in specific
salivary gland diseases.salivary gland diseases.
Like an elevated sodium concentration Like an elevated sodium concentration
with a decrease potassium may indicate with a decrease potassium may indicate
an inflammtory sialadenitis.an inflammtory sialadenitis.

35. 6. Fine- Needle Aspiration Biopsy6. Fine- Needle Aspiration Biopsy

36. 7. Salivary Gland Biopsy7. Salivary Gland Biopsy

37. Obstructive Salivary Gland DeseaseObstructive Salivary Gland Desease
SialolithiasisSialolithiasis
( Salivary Calculi )( Salivary Calculi )
Common in male.Common in male.

Peak incidence between ages 30-50.Peak incidence between ages 30-50.

Multiple stone formation approximately 25%.Multiple stone formation approximately 25%.
 usually unilateral.usually unilateral.

Usually caused by deposition of calcium around a Usually caused by deposition of calcium around a
nidus, subsequently becomes layer to form a calcified nidus, subsequently becomes layer to form a calcified
mass.mass.
Nidus: Mucin, bacteria, epithelial cells.Nidus: Mucin, bacteria, epithelial cells.
Submandibular gland involved in 85% of cases.Submandibular gland involved in 85% of cases.

38. SialolithiasisSialolithiasis
Sign and symptomsSign and symptoms
Pain and swelling at meal time.Pain and swelling at meal time.
Swelling is sudden, usually very painful.Swelling is sudden, usually very painful.
Gradually reduction of swelling, but reoccurs when Gradually reduction of swelling, but reoccurs when
salivary flow is stimulatant.salivary flow is stimulatant.
Process follows untill complete obstruction, infection Process follows untill complete obstruction, infection
occurs.occurs.
Obstruction - atrophy of cellsObstruction - atrophy of cells
Infection - swelling, redness and Infection - swelling, redness and
lymphadenopathy.lymphadenopathy.
Total absence of salivary flow or presence of purulent Total absence of salivary flow or presence of purulent
material.material.

39. SialolithiasisSialolithiasis
Management Management

Depend upon :Depend upon :
Location of stone, Anterior or PosteriorLocation of stone, Anterior or Posterior
Size of stone Size of stone

Small anterior stone, milk forward and Small anterior stone, milk forward and
manipulated may retrieved thoroug the duct.manipulated may retrieved thoroug the duct.

Occasionally, by the procedure of Occasionally, by the procedure of
“S“Sialodochoplasty”.ialodochoplasty”.

Posterior located stone may be removed Posterior located stone may be removed
thorough extraoral approach.thorough extraoral approach.

Recent ECSWL Sucseefully treating the calculi Recent ECSWL Sucseefully treating the calculi
without surgery.without surgery.

40. Mucous Retetion and Extrvasation Mucous Retetion and Extrvasation
CystCyst
1. Mucoceles:1. Mucoceles:
Extravasation cyst of minor salivary Extravasation cyst of minor salivary
gland.gland.
2. Ranula:2. Ranula:
Extravastion or Retention cyst of major Extravastion or Retention cyst of major
gland.gland.
Two Types Two Types
i) Simple Ranulai) Simple Ranula
ii) Plunging Ranulaii) Plunging Ranula

41. Salivary Gland InfectionsSalivary Gland Infections
Sialadenitis:Sialadenitis:
Acute Supprative sialadinitisAcute Supprative sialadinitis
Chronic SialadinitisChronic Sialadinitis
MumpsMumps

42. Acute Suprative SialadinitisAcute Suprative Sialadinitis
Usually due to change in fluide balance Usually due to change in fluide balance
likely to occurs in patients, who are likely to occurs in patients, who are
elderly, debiliated, malnaurished, elderly, debiliated, malnaurished,
dehydrated.dehydrated.
Usually bilaterall.Usually bilaterall.
Mean age 60 years, common in male.Mean age 60 years, common in male.
Caused by variety of organism, single most Caused by variety of organism, single most
common by staphylococous aureus.common by staphylococous aureus.

43. Acute Suprative SialadinitisAcute Suprative Sialadinitis
Clinical FeaturesClinical Features

Rapid onset of swelling.Rapid onset of swelling.

Pain and redness on effected gland.Pain and redness on effected gland.

Rigional lymphnode enlarg and tender.Rigional lymphnode enlarg and tender.

Pus exudes or can be expressed from Pus exudes or can be expressed from
the duct.the duct.

44. Acute Suprative SialadinitisAcute Suprative Sialadinitis
ManagementManagement

Symptomatic and suupportive careSymptomatic and suupportive care

I/v fluid hydrationI/v fluid hydration

Antiobiotc based on C/S.Antiobiotc based on C/S.

Some occasions I&DSome occasions I&D

45. Chronic SialadinitisChronic Sialadinitis

Usually by the complication of duct Usually by the complication of duct
obstructionobstruction

unilateralunilateral

May be asymptomatic or with intermitent May be asymptomatic or with intermitent
painfull swelling of the gland.painfull swelling of the gland.
managementmanagement

Obstruction should be removedObstruction should be removed
More often gland to be excised, examined More often gland to be excised, examined
histologically to exclude a neoplasm.histologically to exclude a neoplasm.

46. Viral parotitisViral parotitis
oror
MumpsMumps
An acute, nonsuppurative communicable An acute, nonsuppurative communicable
disease.disease.
Painfull, nonerythematous swelling of one or Painfull, nonerythematous swelling of one or
both parotide gland.both parotide gland.
Common in children.Common in children.
Usually resolves in 5 to 12 daysUsually resolves in 5 to 12 days

Need supportive and symptomatic care.Need supportive and symptomatic care.
Complication includes, meningitis, pancreatitis, Complication includes, meningitis, pancreatitis,
nephritis, orchitis and testicular atrophy.nephritis, orchitis and testicular atrophy.

47. Necrotizing SialometaplasiaNecrotizing Sialometaplasia
Reactive, nonneoplastic inflammatory process.Reactive, nonneoplastic inflammatory process.
Usually affects minor salivary gland of he palate.Usually affects minor salivary gland of he palate.
Unclear origin, may be due to vascular infarction.Unclear origin, may be due to vascular infarction.
Usual age range 23-66 yearsUsual age range 23-66 years
Painless or painful, deeply ulcerated areas lateral Painless or painful, deeply ulcerated areas lateral
to the palatal mid line.to the palatal mid line.
Resemble to the malignant carcinoma.Resemble to the malignant carcinoma.
Heal spontaneosly within 6-10 days need no Heal spontaneosly within 6-10 days need no
surgical intervention.surgical intervention.

48. Sjogrens syndromeSjogrens syndrome

Most common immunologic disorder Most common immunologic disorder
associated with salivary gland disease. associated with salivary gland disease.

Characterized by a lymphocyte-Characterized by a lymphocyte-
mediated destruction of the exocrine mediated destruction of the exocrine
glands leading to xerostomia and glands leading to xerostomia and
keratoconjunctivitis sicca.keratoconjunctivitis sicca.

49. Sjogrens syndromeSjogrens syndrome
Two forms:Two forms:

PrimaryPrimary: involves the exocrine glands : involves the exocrine glands
onlyonly

SecondarySecondary: associated with a definable : associated with a definable
autoimmune disease, usually autoimmune disease, usually
rheumatoid arthritis.rheumatoid arthritis.

50. Sjogrens syndromeSjogrens syndrome
ManagementManagement
Symptomatic care:Symptomatic care:
i, Artificial tear for dry eyes.i, Artificial tear for dry eyes.
ii, Salivary substitute for dry mouth.ii, Salivary substitute for dry mouth.

51. Neoplastic Salivary gland disordersNeoplastic Salivary gland disorders

Commonly involve the major salivary Commonly involve the major salivary
glands.glands.

75-80% benign in nature.75-80% benign in nature.

Mostly involve the parotid gland.Mostly involve the parotid gland.

52. Neoplastic Salivary gland Neoplastic Salivary gland
disordersdisorders

Benign Salivary gland tumorsBenign Salivary gland tumors
 Pleomorphic adenoma (mixed tumor).Pleomorphic adenoma (mixed tumor).
Warthin’s tumor ( papillary cystadenoma Warthin’s tumor ( papillary cystadenoma
lymphoma tosum).lymphoma tosum).
Monomorphic adenoma.Monomorphic adenoma.
Malignant SG Tumors.Malignant SG Tumors.
Mucoepidermoid carcinomaMucoepidermoid carcinoma
Polymorphous low grade adenocarcinomaPolymorphous low grade adenocarcinoma
Adenoid cystic carcinomaAdenoid cystic carcinoma

53. Benign Salivary gland tumorsBenign Salivary gland tumors
Pleomorphic adenomaPleomorphic adenoma

Most common salivary gland tumor.Most common salivary gland tumor.

The mean age of occerence is 45 years.The mean age of occerence is 45 years.

Male to female ratio is 3:2.Male to female ratio is 3:2.

Parotide gland involve in 80% of the cases.Parotide gland involve in 80% of the cases.

Most common intra oral site is Palate.Most common intra oral site is Palate.

Slow growing painless mass.Slow growing painless mass.

Histologically shows two types of cells.Histologically shows two types of cells.
i, Ductal epithillial celli, Ductal epithillial cell
ii, Myoepithilial cellii, Myoepithilial cell

54. Benign Salivary gland tumorsBenign Salivary gland tumors
Warthin’s tumorWarthin’s tumor
( papillary cystadenoma lymphoma tosum)( papillary cystadenoma lymphoma tosum)

Exclusivly affects the parotide gland.Exclusivly affects the parotide gland.

Paek incidence is the 6Paek incidence is the 6
thth
decade of life. decade of life.

Male to female ratio is 7:1.Male to female ratio is 7:1.

Slow growing painless mass.Slow growing painless mass.

Histologically shows an epithelial component Histologically shows an epithelial component
with germinal centre.with germinal centre.

Treated by surgical excision.Treated by surgical excision.

Recurrence is rare.Recurrence is rare.

55. Benign Salivary gland tumorsBenign Salivary gland tumors
Monomorphic adenomaMonomorphic adenoma

Uncommon solitry massUncommon solitry mass

Composed of one cell type.Composed of one cell type.

Affect predominantly upper lip minor glands.Affect predominantly upper lip minor glands.

Men ag of occurrence is 61 years.Men ag of occurrence is 61 years.

Usually present asymptomatic, freely movable Usually present asymptomatic, freely movable
mass.mass.

Treated by simple surgical excision.Treated by simple surgical excision.

56. Malignant SG Tumors.Malignant SG Tumors.
Mucoepidermoid carcinomaMucoepidermoid carcinoma
Most common malignant SG tumor.Most common malignant SG tumor.
Comprises 10% major gland & 20% minor Comprises 10% major gland & 20% minor
glands.glands.
Mean age is 45 years.Mean age is 45 years.
Clinically present submucosal mass that Clinically present submucosal mass that
may be painful or ulcerated.may be painful or ulcerated.
Treat by more aggressive surgical removal Treat by more aggressive surgical removal
with possibly local radiation therapy.with possibly local radiation therapy.

57. Malignant SG Tumors.Malignant SG Tumors.
Poly morphous low-grade Poly morphous low-grade
adenocarcinomaadenocarcinoma

Second most common introral SG malignancy.Second most common introral SG malignancy.

Common side is is the junction of hard and Common side is is the junction of hard and
soft palate.soft palate.

Male to female ratio is 3:1.Male to female ratio is 3:1.

mean age is 56 years.mean age is 56 years.

Histologically shows many type of cells and Histologically shows many type of cells and
pattern.pattern.

Manage by wide surgical excision.Manage by wide surgical excision.

High recurrence rate (14%).High recurrence rate (14%).

58. Malignant SG Tumors.Malignant SG Tumors.
Adenoide cystic carcinomaAdenoide cystic carcinoma

33
rdrd
most common intra oral SG malignancy. most common intra oral SG malignancy.

mean age is 53 years.mean age is 53 years.

male to female ratio is 3:2.male to female ratio is 3:2.

Present slow growing nonulcerated mass.Present slow growing nonulcerated mass.

Paritide lesion may result facial paralysis as a Paritide lesion may result facial paralysis as a
result of facial nerve involment.result of facial nerve involment.

Treat by wide surgical excision.Treat by wide surgical excision.

The prognosis is poor despite aggressive The prognosis is poor despite aggressive
therapy.therapy.