PAROTID GLAND
CONTENTS
• INTRODUCTION
• DEVELOPMENT
• PAROTID CAPSULE
• EXTERNAL FEATURE AND ITS RELATIONS
• STRUCTURES WITHIN THE GLAND
• PAROTID DUCT
• BLOOD SUPPLY
• NERVE SUPPLY
INTRODUCTION
• Parotid (para= around , otic = ear )
• The parotid is the largest of the salivary glands.
• It weighs around 15g.
• Situated below the external acoustic meatus, between the ramus
of the mandible and the sternocleidomastoid.
• Anteriorly, the gland also overlaps the masseter muscle.
• Accessory parotid lies between the zygomatic arch and the
parotid duct
DEVELOPMENT
• 1st to appear.
• They develop from the buds that arise from the oral ectodermal lining near
the angles of the stomodeum.
• Elongation of the jaws causes lengthening of the parotid duct , with the
gland remaining close to its site of origin.
Later cords canalize and become du
• cts by approx. 10 weeks.
• Rounded ends of the cords differentiate into acini.
• Secretions commence by 18 weeks.
PAROTID CAPSULE
The gland is enclosed within a capsule derived from the investing layer of deep cervical fascia.
The part covering its superficial surface is dense , closely adherent to the gland and attached to the
zygomatic arch.
The deep part of the capsule is attached to the styloid process , the mandible and the tympanic plate
and blends with the fibrous sheaths of the muscles related to the gland.
Portion of the fascia attached to the styloid process and the angle of the mandible is thickened to form
the stylomandibular ligament ( intervenes between the parotid and sub mandibular glands ).
EXTERNAL FEATURES AND ITS RELATIONS
The parotid gland is like an inverted, flattened, three sided pyramid.
It has 4 surfaces :
superior
Superficial
Anteromedial
Posteromedial
3 borders:
Anterior
Posterior
medial
SURFACES
1. Apex: overlaps the posterior belly of digastric and the adjoining part of the
carotid triangle.
Cervical branch of the facial nerve and the two divisions of the retromandibular
vein emerge through It.
2. Superior surface : small and concave , related to
Cartilagenous part of external acoustic meatus
Posterior surface of temporomandibular joint
Superficial temporal vessels
Auriculo temporal nerve
3. Superficial surface : largest of the 4 surfaces , covered with
Skin
Superficial fascia containing anterior branches of great auricular nerve , pre
auricular or superficial parotid lymph nodes and posterior fibres of platysma and
risorius.
Parotid fascia: thick and adherent to the gland.
Few deep parotid lymph nodes embedded in the gland.
4. Anteromedial surface: grooved by the posterior border of the ramus of the
mandible , relations:
masseter
Lateral surface of the TMJ.
Posterior border of the ramus of the mandible.
Medial pterygoid.
Emerging branches of the facial nerve
5. Posteromedial surface: moulded to the mastoid and styloid process and the
structures attached to them.
Mastoid process with the sternocleidomastoid and the posterior belly of digastric.
Styloid process.
BORDERS
1.Anterior border: separates superficial surface from the anteromedial surface
Structures emerging :
Parotid duct
Most of the terminal branches of the facial nerve
Transverse facial vessels
2. Posterior border: separates superficial surface from the posteromedial surface.
Overlaps the sternocleidomastoid.
3. Medial border: separates the anteromedial surface from the posteromedial
surface .
related to the lateral wall of the pharynx
STRUCTURES WITHIN THE GLAND
The external carotid artery enters through the posteromedial surface of the
parotid gland and divides into its terminal branches within its substance.
Maxillary artery emerges from the anteromedial surface and runs forward medial
to the neck of the mandible.
Superficial temporal artery gives off its transverse facial branch and then ascends
to exit from the upper limit of the gland.
Posterior auricular artery -> starts from the ECA within the gland -> leaves from
the posteromedial surface.
Retromandibular vein : formed by the union of maxillary and superficial temporal
veins.
In the lower part of the gland , the vein divides into anterior and posterior division
Posterior division Emerges from the gland behind its inferior extremity and
joins the posterior auricular vein to from the external jugular vein
Before it exits it gives off a communicating branch which leaves the gland in
front of its lower extremity and joins the facial vein and forms common
facial vein
.
Facial nerve traverses on a still more superficial plane
Enters the upper part of the posteromedial surface -> passes forwards and
downwards behind the posterior border of the ramus of the mandible ->
from here terminal branches arise -> exit through the anteromedial surface.
PAROTID DUCT
• 5 cm long
• Begins within the anterior part of the gland -> crosses masseter ->
at the anterior border of the masseter turns inwards -> pierces
the buccal pad of fat, buccopharyngeal fascia ,buccinator -> runs
for a short distance obliquely forwards between the buccinator
and mucous membrane of the mouth -> opens upon a small
papilla on the oral surface of the cheek opposite the crown of the
upper 2nd molar tooth.
BLOOD SUPPLY
Parotid gland is supplied by the external carotid artery and its branches
that arise near the gland.
Veins drain into the external jugular vein.
LYMPHATIC DRAINAGE
Lymph drains first to the parotid nodes and from there to the upper
deep cervical nodes
NERVE SUPPLY
Parasympathetic nerves are secretomotor , they reach the gland
through the auriculo temporal nerve.
preganglionic fibres:
inferior salivatory nucleus
glossopharyngeal nerve
tympanic branch
tympanic plexus
lesser petrosal nerve
relay in the otic ganglion.
Postganglionic fibres: pass through the auriculo temporal nerve
and reach the gland.
Sympathetic nerves are vasomotor and are derived from the plexus
around the middle menengial artery.
CLINICAL ANATOMY
1. Injury to facial nerve during surgery:
Because branches of the facial nerve pass through the parotid
gland , they are in jeopardy during surgery of the parotid.
Important steps in parotidectomy is the isolation and preservation
of the facial nerve .
2. Infection of the parotid gland:
Parotid gland may become infected through the bloodstream as
occurs in mumps.
Severe pain occurs because the parotid sheath limits the swelling.
Pain is worse during chewing because the enlarged gland is
wrapped around the posterior border of the ramus of the
mandible and is compressed against the mastoid process of the
temporal bone.
Frey’s syndrome:
In this condition there is flushing and sweating of skin innervated
by the auriculo - temporal nerve whenever salivation is
stimulated.
Condition follows surgery in the region of the parotid gland or
temporomandibular joint , but may follow accidental injury of the
parotid gland or joint.
It is thought that following injury to the auriculo – temporal
nerve , postganglionic parasympathetic fibres from the otic
ganglion become united to sympathetic nerves from the superior
cervical ganglion destined to supply the vessels and sweat glands
of the skin
Sialoliths: sialoliths are calcified and organic matter that form within
the secretory system of the major salivary glands.
Etiology of sialolith formation is still unknown ; however , there
are several factors that contribute to stone formation.
Inflammation , irregularities in the duct system, local irritants and
anti cholinergic medications may cause pooling of saliva within
the duct.
50% of salivary gland sialoliths are poorly calcified.
Stones in the parotid may be difficult to visualize due to
superimposition of other anatomic structures.
Frey’s syndrome:
In this condition there is flushing and sweating of skin innervated
by the auriculo - temporal nerve whenever salivation is
stimulated.
Condition follows surgery in the region of the parotid gland or
temporomandibular joint , but may follow accidental injury of the
parotid gland or joint.
It is thought that following injury to the auriculo – temporal
nerve , postganglionic parasympathetic fibres from the otic
ganglion become united to sympathetic nerves from the superior
cervical ganglion destined to supply the vessels and sweat glands
of the skin
Sialoliths: sialoliths are calcified and organic matter that form within
the secretory system of the major salivary glands.
Etiology of sialolith formation is still unknown ; however , there
are several factors that contribute to stone formation.
Inflammation , irregularities in the duct system, local irritants and
anti cholinergic medications may cause pooling of saliva within
the duct.
50% of salivary gland sialoliths are poorly calcified.
Stones in the parotid may be difficult to visualize due to
superimposition of other anatomic structures.
Pleomorphic adenoma:
Occurs at any age ( mean age of 42 years )
Accounts for 75 percent of parotid tumours.
Clinically has the texture of cartilage with an irregular and
bosselated surface.
In the palate the mucosa is rarely ulcerated.
Very rarely the tumour may undergo malignant change and for
this reason all patients presenting with pleomorphic adenomas
should be advised to undergo surgical removal of the tumour.
PAROTIDECTOMY
Types :
Partial parotidectomy: resection of parotid pathology with a
margin of normal parotid tissue. This is a standard operation for
benign pathology and low grade malignancies.
Superficial parotidectomy: resection of the entire superficial lobe
of parotid and is generally used for metastases to parotid lymph
nodes.
Total parotidectomy: involves resection of the entire parotid
gland , usually with preservation of the facial nerve.
Extended total parotidectomy : removal of the superficial and
deep parotid gland also may be extended to involve adjacent
structures.
Antegrade approach:
performed by modified blair incision with pre auricular incision.
Skin flap is raised and blunt dissection done just anterior to the external
auditory meatus in an inferior direction.
Anterior border of the sternocleidomastoid is mobilized , retracted
inferiorly to expose the posterior belly of digastric muscle that is traced
upward and backward to its insertion on to the mastoid.
This attachment lies just below the stylomastoid foramen leading to the
facial nerve trunk.
Retrograde approach:
Modified blair incision with a pre auricular was made in the pre
auricular crease.
Skin flap was raised under the periparotid fascia to the superior ,
anterior and inferior borders of the gland.
Stenson’s duct was used as a landmark for identification of the
buccal branch.
Retromandibular vein is used as a landmark for identification of
the marginal mandibular branch.
Zygomatic arch was used as a landmark for the identification of
the zygomatic branch .
As the bifurcation and main trunk of the facial nerve is exposed ,
the gland is resected at the posterior border en bloc along with
the tumour.
Modified Blair Incision
It combines the inverted L-shaped (hockey stick) pre-auricular
incision of Blair with a cervical limb extending into the neck.
Its advantages are exposure of the entire periphery of the gland
and excellent access to the facial nerve. It raises a robust flap that
resists flap necrosis.
The incision further allows extension into a neck dissection
incision and cervicofacial flap elevation
FACIAL NERVE IDENTIFICATION
The nerve lies approximately 1.0–1.5 cm deep and slightly anterior
and inferior to the tip of the external canal cartilage (also called
‘pointer’)
The nerve lies approximately 1.0 cm deep to the medial attachment
of the posterior belly of the digastric muscle to the digastric groove
of the mastoid bone
Tympanomastoid suture: facial nerve lies 6-8 mm deep to this
suture.
Styloid process : facial nerve lies lateral to the styloid process.
REFERENCES
GREY’S ANATOMY – 41st EDITION
B.D CHAURASIA’S HUMAN ANATOMY- SIXTH EDITION
SNELLS CLINICAL ANATOMY
ORAL AND MAXILLOFACIAL SURGERY -NEELIMA MALIK
