SURGICAL ANATOMY
OF
SALIVARY GLANDS
Table of contents
01 Introduction
02 Growth and Development
03 Salivary Gland types
04 Parotid Region with approaches
05 Submandibular region with approaches
06 Sublingual gland with approaches
07 Applied Anatomy
08 Conclusion
INTRODUCTION
• The salivary glands are exocrine glands that make, modify and
secrete saliva into the oral cavity.
• They are divided into two main types: the major salivary
glands, which include the parotid, submandibular and
sublingual glands, and the minor salivary glands, which line
the mucosa of the upper aerodigestive tract and the
overwhelming entirety of the mouth.
• Human salivary glands produce between 0.5 to 1.5 L of saliva
daily, facilitating mastication, swallowing, and speech,
lubricating the oral mucosa, and providing an aqueous
medium for taste perception. .
• They also participate in the digestion of triglycerides and starches by
secreting lipases and amylases.
• In addition, saliva plays a protective role against infections via its many
organic constituents.
• These include the secretory piece, a glycoprotein that forms a complex
with immunoglobulin A (IgA) to defend against viruses and bacteria,
lysozymes that cause bacterial agglutination, autolysin to degrade bacterial
cell walls, and lactoferrin to sequester iron (an element vital to bacterial
growth).
• Additionally, saliva contains ionic compounds, such as bicarbonates, that
buffer acids produced by bacteria and protect the oral cavity and
esophagus from gastric juice. As a result, saliva plays a vital role in
protecting the mouth from chronic buccal mucosal infections and dental
caries
GROWTH AND DEVELOPMENT
• Salivary glands start developing at around 6 to 8 weeks of gestation when
interactions between the epithelium and the adjacent mesenchyme
initiate the thickening of the oral ectoderm.
• The glands develop via the process of branching morphogenesis of
epithelium, involving systematic proliferation, clefting, differentiation,
migration, cell death, and mesenchymal, epithelial, endothelial, and
neuronal cell interactions.
• This branching process also occurs in other organ systems, including the
lungs, kidneys, and mammary glands .
• The terminal buds at the end of the branched ductal structures become
acini at 14 weeks.
• While the parotid gland is the first to begin its formation, the
development of lymphatic tissue throughout the gland makes it the
last of the glands to be enclosed in connective tissue and the only
salivary gland with an enclosed lymphatic system.
• Human SMGs are well-differentiated by 13 to 16 weeks, featuring
microvilli and desmosomes from cells near the lumens. The basal
lamina surrounds the epithelium, and myoepithelial cells are
thought to begin to appear at this stage.
• After 16 weeks, striated and intercalated ducts can be noticed. The
glands stop developing at 28 weeks, marking the point at which
acini produce secretory products.
• The glands are fully functional at birth
PAROTID GLAND, SURGICAL ANATOMY
AND ITS SURGICAL CONSIDERATIONS
Anatomical Location
The parotid gland (PG) is the largest of the three major salivary glands.
It is located between the sternocleidomastoid muscle and the masseter,
extending from the mastoid tip to just below the angle of the mandible.
A small tail projects from the inferior edge of the gland, separated by the
submandibular space only by the stylomandibular ligament.
From superficial to deep, the gland is superficial to the facial nerve, an area of
crucial surgical relevance, followed by the retromandibular vein and the
external carotid artery.
Stensen’s duct, the main excretory duct of the PG, projects from the anterior
portion of the gland over the masseter. In its trajectory, it pierces the buccinator
muscle to open into the oral cavity at the level of the buccal mucosa of the
second maxillary molar
THE PAROTID FASCIA
• The parotid is enclosed in a split in
the investing fascia
• The parotid lymph nodes lie both on
and below the parotid gland.
• Antero-inferiorly, the fascia is
thickened to form the
stylomandibular ligament
• The only structure that separates the
parotid from the submandibular
gland.
PAROTID DUCT
STRUCTURES WITHIN THE GLAND
Structures passing through the gland
Facial nerve
a. Enters gland and branches into two stems
b. Two stems give rise to five branches that
emerge from borders of gland
Superficial temporal vein
a. Runs through deeper part of gland
b. Unites with maxillaryvein within the gland to
form retromandibular vein
External carotid artery
through deep part of gland
STRUCTURES WITHIN PAROTID GLAND
RETROMANDIBULAR VEIN:-
UNION OF SUP. TEMPORAL AND MAX. VEINS
EXT.CAROTID ARTERY:-
LEAVES CAROTID TRIANGLE BY PASSING DEEP TO POST. BELLY OF
DIGASTRIC,ASCENDS AND ENTERS PAROTID GLAND
AURICULOTEMPORAL NERVE:-
ARISES FROM POST. DIV OF MANDIBULAR DIV OF TRIGEMINAL
NERVE AND ENTERS ANTEROMEDIAL SURFACE OF PAROTID
GLAND,PASSES UPWARD AND OUTWARD TO EMERGE AT SUP.
BORDER OF THE GLAND
RELATIONS OF PAROTID GLAND:-
-SUPERFICIAL RELATION:-
PAROTID LYMPH NODES,GREATER AURICULAR
NERVE,SKIN,SUP.FASCIA
-SUPERIOR RELATION:-
EXT.AUTIDORY MEATUS,POSTERIOR SURFACE
OF TMJ,GLENOID LOBE
-POSTEROMEDIAL RELATION:-
MASTOID
PROCESS,STERNOCLEIDOMASTOID,POST.BELLY
OF DIGASTRIC,STYLOID PROCESS,CAROTID
SHEATH,ICA,IJV &
(VAGUS,ACESSORY,GLOSSOPHARYNGEAL,HYPO
GLOSSAL,FACIAL)
NERVES
-ANTEROMEDIAL RELATION:-
POSTERIOR BORDER OF RAMUS,TMJ,MEDIAL
PTERYGOID,TEMPORAL BRANCH OF FACIAL
NERVE AND STYLOMANDIBULAR LIGAMENT
IDENTIFYING THE FACIAL NERVE
The facial nerve identification can be done either proximally
or distally.
Proximally the main trunk of the nerve is identified before it enters the gland.
Distally it is identified as branches after the nerve leaves the gland
There are four facial nerve pointers at the stylomastoid
foramen. They are as follows:
1. The cartilaginous pointer of Conley (1978)
is created at its anterior inferior border and is the least
reliable one.
The backward pull on the cartilage causes the meatus to
assume the shape of a horn, the curved extremity of which
allegedly points to the position of the facial nerve. The
nerve is located medial and inferior to the pointer
2. A short segment of the facial nerve lies in between the
stylomastoid foramen and parotid gland
and is an ideal location to identify it. It can be located in the
tympanomastoid sulcus which is formed by the edge of the bony
external meatus and anterior face of the mastoid process.
The nerve emerges from the stylomastoid foramen some 3–4 mm
deep to the outer edge of the bony external canal.
The tympanomastoid sulcus is filled with fibrofatty lobules that
mimic the facial nerve trunk which may lie as deep as 1 cm to this
landmark
3.The anterior superior aspect of the posterior belly of the digastric
muscle is inserted just behind the stylomastoid foramen. The
posterior belly of the digastric muscle lies just inferior to the nerve
and is the most reliable landmark to identify the nerve
4. The styloid process is a confirmatory landmark. The facial nerve lies
lateral to the styloid process near the styloid base. The posterior
auricular artery bleeds frequently while looking for the facial nerve
since it lies below and just lateral to the nerve, and hence it cannot be
relied upon for identifcation of the nerve
5. Borle’s triangle has been recently
introduced to locate the facial nerve trunk.
The facial nerve trunk is often found
within this triangle just above the angle b
formed by the first and the third line if
gentle and blunt dissection is carried out
at this point.
The mean distance of nerve trunk from
the angle b is 12.18 ± 2 mm within a
range of 9–15 mm
Retrograde approach
Can be used by identifying a peripheral branch of the nerve and
tracing it proximally.
The easiest branch to locate is the marginal mandibular nerve.
Authors have reported that the marginal mandibular nerve
is located 1–2 cm below the inferior border of the mandible.
The marginal mandibular branch can be used to trace the
facial nerve in a retrograde direction by identifying it at the
point of emergence of the retromandibular vein and then carrying
out a proximal dissection.
By working backward along the nerve, the two divisions, the other
branches, and the main
trunk can be found
Distance from facial nerve pointers
Facial Nerve Monitoring
There are two types of facial nerve monitoring:
• Electromyography
• Pressure or strain gauge sensor
Facial nerve monitoring is performed with a nerve stimulator which can
either be monopolar or bipolar. The monopolar stimulator is more useful
for identifying the nerve, while
the bipolar is more useful if the nerve course is evident.
However, a bipolar stimulator is more precise
The intratemporal and intraparotid facial nerve has varied pattern of branching which
is of immense surgical importance and might show bifurcation and trifurcation of the
main
trunk within the mastoid segment .
This intratemporal division of the facial nerve is associated with congenital
abnormalities of the pinna or inner ear
FACIAL NERVE:-
1) TEMPORAL
2) ZYGOMATIC
3) BUCCAL
4) MARGINAL MANDIBULAR
5) CERVICAL
SURGICAL APPROACHES TO THE PAROTID GLAND
Several approaches to the Parotid have been proposed and are used clinically. The
standard and most basic is the preauricular approach and its modifications. Other
approaches differ in the placement of the skin incision, as well as access to the gland.
STEP 1. Preparation of the Surgical Site
Preparation and draping should expose the entire ear and lateral
canthus of the eye. Shaving the preauricular hair is optional. A
sterile plastic drape can be used to keep the hair out of the
surgical field. Cotton soaked in mineral oil or antibiotic ointment
may be placed in the external auditory canal
STEP 2. Marking the Incision
The incision is outlined at the junction of the facial skin with the helix of the ear. A
natural skin fold along the entire length of the ear can be used for incision. If none is
present, posterior digital pressure applied on the preauricular skin usually creates a skin
fold that can be marked . The incision extends superiorly to the top of the helix and may
include an anterior (hockey-stick) extension
STEP 3. Infiltration of Vasoconstrictor
The preauricular area is quite vascular. A vasoconstrictor can be injected
subcutaneously in the area of the incision to decrease incisional bleeding. However,
if local anesthesia is also being injected, it should not be injected deeply because it
may be necessary to use a nerve stimulator on exposed facial nerve branches.
STEP 4. Skin Incision
The incision is made through skin and subcutaneous connective tissues
(including temporoparietal fascia) to the depth of the temporalis fascia
(superficial layer). Any bleeding skin vessels are cauterized before
proceeding with deeper dissection
Choice of Skin Incisions
Gutierrez (1903)—The incision had a temporal extension,
a preauricular component, and a limb extending onto the
neck in one of the skin creases.
The chief drawback of this incisions was esthetics in case
of development of a keloid.
Adson and Ott - a “Y”-shaped incision with a
preauricular part, a postauricular part, and a
cervical incision line that splits off from the site of
union of the first two branches
The advantage of this incision is improved
esthetics because it lacks a temporal incision line,
but
the drawback is that it impairs dissection. Also,
one section of the incision is located in the carotid
region.
Samengo (1961)—The incision has a preauricular, a
postauricular, and a neck extension
Appiani (1967)—The incision within the lower
portion of the scalp is hidden by the hair
instead of the vertical incision line.
The advantage of this incision is better
esthetics.
However, the temporal extension of this
incision is short, and this impairs access to the
anterior portion of the gland
The Blair incision
an S-shaped incision that starts from the
preauricular region and extends in the neck.
The major disadvantage of the Blair incision is
a visible scar in the neck that may cause facial
or cervical disfigurement causing patients
dissatisfaction.
Modifed Blair incision The standard incision,
wherein the skin incision is placed in a
preauricular crease and doesn’t extend beyond
the level of the root of the helix. It extends
inferiorly around the ear lobule over the
mastoid tip. It gently curves down along the
sternocleidomastoid muscle and then slightly
forward in a natural crease in the upper neck
A facelift incision can be used to avoid the
hollowing after parotidectomy, and the defect
can be filled with SMAS advancement fap
(Bananno and Casson, 1992).
However, the SMAS-lifting technique is not a
routine procedure for many surgeon
STEP 5 : DEEPEN SKIN INCISION
SUBMANDIBULAR GLAND, SURGICAL ANATOMY
AND ITS SURGICAL CONSIDERATIONS
ANATOMIC LOCATION
The submandibular gland (SMG), the second-largest gland, is about
one-half the weight of the parotid and is found inferior to the
mandible, between the anterior and posterior bellies of the digastric
muscle.
The SMG has a smaller anterior lobe and a larger posterior lobe and is
J- shaped.
The lobes are connected in the posterior free edge of the mylohyoid
muscle.
The main excretory duct, referred to as Wharton’s duct, arises from
the smaller, deep lobe inferior to the mucosa of the floor of the
mouth to enter the oral cavity an open into the frenulum linguae at
the sublingual caruncle.
The hypoglossal nerve runs parallel and inferior to Wharton's duct
SUPERFICIAL PART
This part of the gland fills the digastric triangle.
It extends upwards deep to the mandible up to
the mylohyoid line.
It has:
a. Inferior
b. Lateral
c. Medial surfaces.
The gland is partially enclosed between two layers
of deep cervical fascia. The superficial layer of fascia covers the
inferior surface of the gland and is attached to the base of the
mandible.
The deep layer covers the medial surface of the gland and is attached
to the mylohyoid line of the mandible
Relations
The inferior surface is covered by:
a. Skin
b. Platysma
c. Cervical branch of the facial nerve
d. Deep fascia
e. Facial veim
f. Submandibular lymph nodes.
The lateral surface is related to:
a. The submandibular fossa on the mandible.
b. Insertion of the medial pterygoid
c. The facial artery
The medial surface is related to:
Mylohyoid, hyoglossus and styloglossus muscles
from before backwards
Inferiorly: It overlaps stylohyoid and the posterior
belly of the digastric
DEEP PART
This part is small in size.
It lies deep to the mylohyoid, and superficial to the hyoglossus
and the styloglossus.
Posteriorly, it is continuous with the superficial part round the
posterior border of the mylohyoid.
Anteriorly, it extends up to the posterior end
of the sublingual gland.
WHARTON’S DUCT
It is thin walled, and is about 5 cm long.
It emerges at the anterior end of the deep part of the gland and rims forwards on
the hyoglossus, between the lingual and hypoglossal nerves.At the anterior border
of the hyoglossus, the duct is crossed by the lingual nerve.
It opens on the floor of the mouth, on the summit of the sublingual papilla, at the
side of the frenulum of the tongue
The submandibular duct or Warton’s duct is longer and has a tortuous, uphill
course.
Thus the secretions have to be emptied against gravity, and there are increased
chances of retention.
Also, the mineral content of the secretion is high, especially calcium content
which along with increased retention of secretions results into higher incidence of
calculus formation and inflammatory pathologies in the submandibular gland and
duct
It is a U-shaped gland with a smaller deep lobe and larger superfcial lobe
enveloping the mylohyoid muscle.
Hence during surgical removal, the mylohyoid has to be retracted anteriorly to
expose the deep lobe and the Wharton’s duct.
The capsule is loosely attached to the gland substance, and hence the gland can
be shelled out easily
Since the submandibular group of lymph nodes are in contact with the gland or
embedded in it, it is essential to clear the nodes along with the gland during a neck
dissection.
The facial artery loops around the submandibular gland. The facial artery is visualized
by retracting the posterior belly of the digastric muscle inferiorly. Hence, during
excision of the submandibular gland, the facial artery and vein were customarily
ligated.
However, during neck dissection, the current standard is to try and save it so that
it can be used for anastomosis during a free flap reconstruction
The facial artery is ligated away from the external carotid artery, so that in case the vessel
retracts into the tissue, it can be located and re ligated and bleeding can be controlled. In
case the ligature slips and the facial artery retracts, the posterior belly of the digastric muscle
is divided for easy location of the bleeding vessel.
The lingual nerve passes below the duct and forms a loop around its outer aspect before
inserting into the tongue mucosa. It is at risk when the deep part of the gland is being
mobilized.
APPROACH TO THE SUBMANDIBULAR GLAND
The submandibular approach is one of the most useful approaches to the
mandibular ramus and posterior body region, and is occasionally referred to as
the Risdon approach. Apart from exposing the gland, this approach may be
used for obtaining access to a myriad of mandibular osteotomies, angle/body
fractures, and even condylar fractures and temporomandibular joint (TMJ)
ankylosis.
The incision should be
placed 1.5 to 2 cm inferior
to the
anticipated location of the
inferior border.
The incision is located
along a suitable skin
crease in the
anteroposterior position
that is needed for
mandibular exposure
SUBLINGUAL GLAND, SURGICAL
ANATOMY AND ITS SURGICAL
CONSIDERATIONS
The sublingual gland (SLG) lies beneath the mucosa of the floor of the mouth and superior
to the mylohyoid muscle (between the mandible and genioglossus muscles). Medially,
between the base of the tongue and the sublingual gland, the submandibular duct, and the
sublingual nerve can be found.
Rather than having one main duct, it contains a series of short ducts that project directly
into the floor of the mouth, the ducts of Rivinus, and a common duct, known as Bartholin's
duct that connects with the submandibular gland's duct at the sublingual caruncula
Relations
Front - Meet with opposite side gland
Behind - Comes in contact with deeper part of
submandibular gland
Above - Mucous membrane of mouth
Below - Mylohyoid muscle
Lateral - Sublingual fossa
Medial - Genioglossus muscles
About 15 ducts emerge from the gland. Most of them
open directly into the floor of the mouth on the summit
of the sublingual fold. The gland receives its blood
supply from the lingual and submental arteries. The
nerve supply is similar to that of the submandibular
gland.
SUBLINGUAL GLAND DUCTS
Approximately a dozen or more sublingual glands a/k/as DUCTS OF RIVINUS pass from
The upper border of the gland >>>> sublingual fold>>> empty directly into the buccal
cavity,
Some of the anterior sublingual ducts unite together to form a Major duct a/k/as the
DUCT OF BARTHOLIN
BARTHOLIN DUCT joins WHARTONS DUCT and empty at the sublingual caruncle
SURGICAL APPROACH TO THE
SUBLINGUAL GLAND
A linear incision in the floor of the mouth
parallel and just lateral to submandibular duct.
Whartons identified and retracted medially
Lingual nerve to be preserved
Gland on inner cortex of mandible mobilized
MINOR SALIVARY GLANDS
References
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