salivary glands

Salivary glands

Types
Major salivary glands:
- parotid g.
- Submandibular g.
- Sublingual g.

Minor saliovary gland :

consists of 750 g scattered through out the submucosa of the oral cavity,oropharynx, hypopharynx,larynx and parapharyngeal space


Surgical anatomy
Parotid gland:
-largest g.
-related to facial n which pass through the g and divides it to superficial and deep lobe .
- the duct (stensen’s duct)cross the masseter m.then the buccinator m . And inter the oral cavity through a small papillae opposite the 2nd upper moler .

Submandibular gland :

It lies in the digastric tiangle the anterior portion extend in contact with the floor of the mouth, the duct (wharton’s)open near the frenulum of the tongue.

The sublingual gland

Lies in contact with the submandibular duct . It is short ,multiple ducts enter directly to the floor of the mouth .

Surgical physiology

Amount of saliva from1 -1.5 liter/24h.
Content :water+Ca and Phosphate salts.
It assist in food lubrication and swallowing ,cleaning of mouth, mediate taste sensation and initiate digestion of starch by amylase.
Parotid g. secreats mainly serous saliva.
Submandibular g. mixed (mucous ,serous)rich in Calcium.

Diseases of salivery glands

1- Developmental disorders:
-Aplasia
-Duct atrasia
-Salivery fistulae (congenital)
-Accessory lobe 20%

2- Infections:

A- acute bacterial sialoadenitis:
- Affect mostly the parotid glands
- Usually staph. aureus or strept. veridance
- In elderly dehydrated ,teminal pt ,after major surgery with poor oral hyogen or when patient nil by mouth(post operative ).
- Stone obstruction
- Sjogren syndrom.

Clinical presentation

Sever pain in the parotid region.
Pain is exacerbated by eating or drinking and resolution of pain within 1 hour.
Swelling localized in the lower pole of the gland(gravity).
No fluctuation because tight fascia , only redness and edema.
We can see pus coming out from the opining of the duct in oral cavity.


Diagnosis
Never to do sialography in the acute phase.
U/S of the gland either dilatation of the acinae or abscess .
CT of the glands

Treatment

Mouth toilet
Rehydration
Local heat
Antibiotics (against G+)
Surgical drainage :if no response after 48 h must be UGA and pus for C/S and drain left.
aspiration s.t. also may be effective.

B- Chronic bacterial sialoadinitis

Usually due to chronic obstruction by stone
More common in the submandibular g.
Either unilateral or bilateral.
Clinically :- attacks of pain and swelling after meal .
- redness of the orifice of the duct at the side of the frenulum .
- swelling filling the floor of the mouth.


Treatment
The gland has poor capacity for recovery after infection .So after dealing with the infection we have to excise the gland or diletation of the stricture .

C- recurrent sialadinitis of chilhood

Of unknown aetiology and prognosis
The age between 3-6y
Clinically: - rapid swelling with pain after chewing lasts for 3-7 days.
- usually unilateral but 2nd episode may be the other side.
- systemic manifistation.

Diagnosis

Sialogrphy with punctate sialactasis.or snow storm appearance .
Treatment : message &antibiotic
- if recurrent give antibiotic as prophylaxis for months or years .spontaneous resolution at puberty .
- surgical excision only in resistant cases.

D -Viral parotitis (mumps)

Is the commonest cause of infection in children.
Clinically : 1-pain and swelling of one or both sides with fever .
2- resolve spontaneously after 5-10 days. with lifelong immunity.

E- Granulomatus infection

It is a specific infection .either mycobacterial infection or sarcoidosis .(rare) affect the L.N.
of the gland.

3- Obstruction

Papillary obstruction:

rough upper molar tooth irritate the papilla and cause inflammation edema.

Stone formation (sialolithiasis)

Predisposing factors :
-Stases
- Infection

INCIDENCE

Submandibular g. stone to parotid 50:1
Why ?
The cource of the duct transverse and against gravity .(stasis)
The secretions contain ca.
the opining of the duct in the floor of the mouth liable to block by food particles

Clinical presentation

The stone lie in the hilum of the gland or in the duct .
The patient complaining from frequent attacks of pain and swelling or just discomfort.
Bimanual palpation feel stone in the floor of the mouth .
May present as acute attack of sialadinitis
Asymptomatic .

Investigations

plain X-ray : 80% opaque due to ca carbonate or phosphate .
Sialography :used for parotid stone mainly if radiolucent as filling defect .


Treatment
1- ductal stones:
- Gentle probing and dilatation of the papilla
Theraputic sialendoscopy
Slit the duct longitudinally intra orally
Shock wave (lithtrepsy) rare
2- Stone within gland substance :
Needs excision of the gland.

Mucoceles

Mucous retention cyst in the minor salivary gland due to mechanical damage to the gland or its duct in the lower lip. The cyst not more than 1 cm and tense sessile bluish swelling

Treatment :the underlying gland should be excised completely ULA .

Ranula (frog belly)

It is a large mucocele which arise from the sublingual gland .
As bluish swelling in the floor of the mouth anteriorly displacing the tongue .
It may go through the mylohyoid to reach the submental space (plunging ranula).
Treatment :deroofing or marcepialization

4- Drug induced swelling

Chloramphinicol ,tetracyclin .
Endocrine and metabolic enlargment .

5-Salivery fistulae

Causes :
1- accidental trauma.
2- surgical complication .
3- stone ulcerating to mouth (internal fistulae).

Investigation :sialography.

Treatment :
1- canulation of distal part of duct from inside of mouth and trial of repair.
2- if this fails then excision .
3- if internal fistulae no need for treatment.


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