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commonly squamous cell carcinoma (85%). Lymphoma,
minor salivary tumours and sarcoma are other malignancies
that can occur rarely in nasopharynx.
It can be of proliferative, ulcerative, and infiltrative types.
Commonest site is fossa of Rosen
muller in lateral wall of
pharynx. It is three times common in males.
HO’s triangle in supraclavicular fossa (bounded by medial
and lateral ends of clavicle and point where neck meets the
shoulder) is the site where metastatic nodes commonly exist
in nasopharyngeal carcinoma.
In 50% of cases nodal involvement is bilateral. Often cervical
lymphadeno
SRB's Manual of Surgery
Clinical features may be nasal, otogenic, ophthalmoneuro-
pathy may be the first presentation.
It is common in people working in furniture industries,
mustard gas industries, and leather industries. It is common
in Bantus in South Africa where snuff with nickel and chromium is commonly used.
Types
Squamous cell carcinoma 80%.
Adenocarcinoma.
Transitional cell carcinoma.
Salivary gland tumours.
Sarcomas and melanoma.
Burkitt’s lymphoma.
genic (involving most of the cranial nerves with facial pain,
squint, diplopia, exophthalmos, and ophthalmop
legia),
jugular foramen syndrome (cranial nerves IX, X, XI spread),
nodal spread and distant spread to bones, lungs and liver.
Unilateral serous otitis media may be the only presentation.
Features
Epistaxis, nasal speech, post-nasal discharge and nasal
obstruction.
Pain in the ear with unilateral deafness due to compression
of Eustachian tube with fluid collection in the middle ear.
Elevation and immobility of soft palate on the same side.
Pain in the area of distribution of trigeminal nerve due to
direct infiltration of the nerve at foramen lacerum.
Palpable secondaries in upper deep cervical lymph nodes
(70%).
TROTTER‘S TRIAD
B
x Unilateral deafness
x Immobile elevated soft palate
x Pain in the distribution of trigeminal nerve
Differential Diagnosis: Lymphoma; Lymphoepithelioma;
Minor salivary gland tumour.
Investigations: Biopsy from the primary site; FNAC from the
neck lymph nodes; X-ray of the skull to visualise erosions;
CT scan skull.
Treatment:
¾
External irradiation for primary. RT is the main modality
of treatment.
¾
Radical block dissection of cervical lymph nodes.
¾
In N2a, N2b and N2c contralateral neck dissection is
needed. Spinal accessory nerve is never preserved while
doing block dissection in nasopharyngeal carcinoma.
¾
Chemotherapy: Methotrexate, Vincristine.
¾
Skull base surgeries are useful.
Fig. 3.75: Carcinoma maxillary sinus in a boy. Note the extension
into the palate.
Behaviour and Presentation
Initially may be symptomless or may present with epistaxis
or features of chronic sinusitis.
When it spreads to the floor, loosening of the teeth, necrosis,
antro-oral fistula can occur.
Extension medially causes nasal block, fungation, nasal
discharge, blockage of nasolacrimal duct (epiphora).
Extension anteriorly causes pain, anaesthesia and swel ling
in the cheek, ulceration and fungation in the skin of cheek.
Spread above into the orbit causes epiphora, diplopia, proptosis.
Posterior spread is most dangerous as it is not revealed
easily. It causes postnasal discharge, pain, trismus, limitation
of temporomandibular joint movement.
Involvement of upper deep cervical lymph nodes in later
stage is common.
Differential diagnosis: Chronic sinusitis.
Classication
MAXILLARY TUMOURS
They are rare.
Maxillary sinus is the commonest site for malignancy of
paranasal sinuses. Ethmoids, frontal and sphenoids are next
in order.
1. Ohngren’s classification
An imaginary plane is drawn extending between medial canthus
of eye and the angle of mandible. Growth situated above this
plane is called as suprastructural which has got poor prognosis.
Growth below this plane is called as infrastructural and has got
better prognosis.
2. Lederman’s classification
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Two horizontal lines are used, one passes through the floor of
the orbit, another passes through the floor of the antra. These
lines are called as line of Sebileau.
Suprastructure type: In this type olfactory area of nose,
ethmoidal, sphenoid, and frontal sinuses are involved.
Mesostructural type: This involves maxillary sinus and nasal
respiratory part.
Infrastructural type: This type involves alveolar process.
Lederman’s classification is further divided by two vertical
lines over medial walls of the orbit to separate ethmoid sinuses
and nasal fossa from maxillary sinuses.
Contd...
T4 – T4a: Moderately advanced local disease—Tumour invading
anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid and frontal sinuses. T4b: Very
advanced local disease—Tumour invading orbital apex, dura, brain,
middle cranial fossa, cranial nerves other than maxillary division of
trigeminal nerve, nasopharynx or clivus
N – Nodes: same as oral cavity.
Staging
Stage 0: Tis N0 M0.
Stage I: T1 N0 M0.
Stage II: T2 N0 M0.
Stage III: T3 N0 M0; T1, T2, T3 N1 M0.
Stage IV: IVA: T4a N0/N1 M0; T1, T2, T3, T4a N2 M0. Stage IVB: Any
T N3 M0; T4b Any N M0. Stage IVC: Any T Any N M1.
Diagnosis
X-ray of the part—pacity of the involved sinus with destruc-
tion of bony walls is seen—Water's PNS view.
CT scan—ideal method.
Sinus endoscopy for detailed examination of sinus and for
biopsy.
Biopsy is done through nasal/oral or on early stage through
Caldwell-Luc operation.
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CHAPTER 3 Oral Cavity
Fig. 3.76: An imaginary plane is drawn extending between medial
canthus of eye and the angle of mandible and line in this plane is called
as Ohngren’s line.
Fig. 3.77: Diagrammatic representation of Lederman’s classification.
TNM STAGING OF MAXILLARY TUMOURS (AJ
B
T – Primary tumour
Tx – Primary tumour cannot be assessed
Tis – Carcinoma in situ
T1 – Tumour limited to maxillary sinus mucosa with no erosion or
destruction of bone
T2 – Tumour causing bone erosion or destruction including extension
into the hard palate and or middle nasal meatus except extension to
posterior wall of the maxillary sinus and pterygoid plates
T3 – Tumour invades either the bone posterior wall of the maxillary
sinus, subcutaneous tissue, floor or medial wall of the orbit, pterygoid
and ethmoid sinuses
Contd...
Efforts and energies should be consistent, constructive and compassionate.
Treatment
Pre-operative megavoltage radiotherapy is given. After six
weeks, total maxillectomy is done. Recons truction of maxilla
along with dental reconstruction is required.
When lymph nodes are involved radical neck lymph nodes
dissection is done.
Post-operative radiotherapy and chemotherapy is given as
an adjuvant therapy.
Overall prognosis is 30–40%.
Fig. 3.78: Incision for Caldwell-Luc operation which is used for taking
biopsy from maxillary tumour. Incision is not used for definitive
therapy for carcinoma maxilla. Incision also used in benign conditions
to approach maxillary sinus. Gingivobuccal mucosa is incised and
mucoperiosteum is raised. Bone of canine fossa is cut to reach the
maxillary antrum.
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Fig. 3.80: Carcinoma maxillary antrum extending outwards on to all
SRB's Manual of Surgery
A
walls. An advanced malignancy.
B
C
D
Figs. 3.79A to D: Carcinoma maxilla extending into the nose with
X-ray and CT pictures. It is a fairly advanced growth.
Fig. 3.81: Weber-Ferguson’s incision used for total maxillectomy.
MALIGNANT TUMOURS OF TONSIL
Carcinoma of tonsil: It is squamous cell carcinoma, similar to
carcinoma cheek, but more aggres
Carcinosarcoma of tonsil.
Lymphoma—NHL type.
Fig. 3.82: Lymphoepithelioma of tonsil.
sive with poor prognosis.
CARCINOMA HARD PALATE
Minor salivary gland tumours are more common in palate.
In males, in reverse smokers (Churat is rolled tobacco leaf)
squamous cell carcinoma is seen in palate due to repeated
thermal injury.
Malignant tumours may spread to periosteum, bone, maxilla,
sinus, or nose.
Salivary gland tumours are commonly malignant and are of
adenoid cystic type. Other types also can occur. It presents as
a single, solid, smooth swelling with ulcer over the summit.
Squamous cell carcinoma is ulcerative with raised and everted
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edge.
Upper deep cervical lymph nodes are involved in 25% of patients.
Investigations are wedge biopsy, FNAC lymph node and CT
scan to see extensions.
Treatment is wide excision with removal of the underlying palatal
bone. Often partial or total maxillectomy (Weber-Ferguson incision) may be required. Myocutaneous flap with dental prosthesis
is essential to reconstruct after surgery. Postoperative radiotherapy and neck block dissection are often required.
Fig. 3.83: Carcinoma hard palate extending laterally.
LARYNGEAL TUMOURS
Benign
Epithelial can be papilloma, vocal nodule or vocal polyp.
Papilloma is usually single in adult, multiple in children.
Connective tissue tumours like fibroma, myxoma, angioma.
Indirect laryngoscopy (ILS) or direct laryngoscopy confirms
the diagnosis. videolaryngoscopy is better.
Childhood papilloma Adult papilloma
Multiple, of viral origin (Papova) Single, of neoplastic origin
Can occur in glottic, supra and
infraglottic
Not premalignant Premalignant
Recurrence common Not common after
Excision is difficult Easier removal
Causes more dyspnoea, stridor, cough Hoarseness only
May require tracheostomy
Glottic only
complete excision
benzopyrones, petroleum products; Previous radiation;
Genetic: Russians develop familial laryngeal cancers; Papillomavirus, keratosis, malnutrition.
Incidence: Squamous cell carcinoma is commonest (95%);
Common in males (10 : 1); Common in 5th/6th decade.
Types: Ulcerative; Proliferative.
Anatomical Types
Supraglottic (25%):
¾
It arises from infrahyoid part of epiglottis, ventricles, and
arytenoids. It spreads to neck lymph nodes early (40%)
due to rich lymphatics in this area. Throat pain, dysphagia,
palpable neck nodes and referred pain are common
features. Hoarseness of voice, loss of weight, respiratory
obstruction, and halitosis are late features. Carcinoma
in epiglottis causes bilateral nodal spread. Local spread
occurs to vallecula, base of tongue and pyriform fossa.
Glottic (65%):
¾
It is the commonest type. It begins from upper part or free
edge of vocal cords (mid or anterior) often extending 10
mm below. Lymphatic spread is slow (only 4%) as this area
has got least lymphatics. Opposite vocal cord can involve
as kiss cancer. Vocal cord mobility is unaffected in early
cases. Vocal cord fixation signifies spread to thyroarytenoid
which is a poor prognostic sign. It presents very early
due to hoarseness of voice. Eventual cord fixation causes
stridor. Locally it spreads anteriorly to anterior commissure, posteriorly to vocal process and arytenoids, above to
ventricle and false vocal cords, below to subglottis.
Subglottic (2%)
¾
Is less common involving under-surface of true vocal
cords and subglottic space. It spreads to deep cervical and
paratracheal nodes (20%). Upward spread is rather late and
so hoarseness is not an early symptom in this type. It can
spread through cricothyroid membrane or thyroid gland.
Note:
• In Indian subcontinent supraglottic tumours are more common than
glottic. Glottic type is common in Western countries.
• Fixation of cords is due to involvement of thyroarytenoid muscle or
cricoarytenoid joint.
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CHAPTER 3 Oral Cavity
Note:
Stridor can be inspiratory, expiratory or biphasic.
Treatment: Endoscopic removal. Application of podophyllum;
Cryosurgery, laser surgery.
MALIGNANT TUMOURS OF LARYNX
Aetiology: Smoking, tobacco; Alcohol intake; Occupational/
industrial exposure to chemicals like mustard gas, asbestos,
Your feelings are your God; our doubts are traitors and make us lose the good we oft might win.
Fig. 3.84: Anatomy of larynx showing supraglottic, glottic and
subglottic regions.
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In advanced resectable tumours, induction chemotherapy
for 3 cycles with methotrexate and cisplatin 100 m/sq metre
BSA (at 0, 22. 43 days) and total laryngectomy is under trial.
Concurrent chemotherapy and radiotherapy are also under
trial in these cases.
SRB's Manual of Surgery
Fig. 3.86: View of larynx as seen through a laryngoscope.
Fig. 3.85: Laryngeal carcinoma, types. Note the typical sites. Glottic
is the commonest site. Next is supraglottic. Subglottic is rare.
Treatment
Supraglottic: Stage I—curative radiotherapy is the choice.
In stage II and III total laryngectomy and block dissection
of neck nodes.
Glottic: Radiotherapy is the choice as nodes are commonly
not involved. Endoscopic laser surgery or open partial laryngectomy can be done.
Clinical features Investigations
• Hoarseness of voice • ILS (Indirect laryngoscopy)
• Pain and discomfort • Direct laryngoscopy and biopsy
•
Cough, dyspnoea, stridor,
dysphagia in late cases
Bloody sputum
•
•
Palpable neck nodes,
which eventually get fixed
• Absence of laryngeal
crepitus
• Common in males—10:1 • Toluidine blue staining to stain
Subglottic: Total laryngectomy is the treatment of choice with
nodal block when needed.
In advanced stage IV carcinomas surgery and radiotherapy
both are not possible. Here chemotherapy is given using
cyclophosphamide, cis platin and methotrexate.
• CT neck—very useful
investigation
• Chest X-ray
• FNAC of lymph node
• Microlaryngoscopy in small
lesions to identify and to have
proper biopsy
early superficial cancers which
facilitate the accurate biopsy
•
Hopkin’s endoscopy
• Flexible, fibreoptic laryngoscopy
A
Figs. 3.87A and B: (A) Carcinoma larynx—patients underwent total
laryngectomy with permanent tracheostomy; (B) Gluck-Sorenson's
laryngectomy incision. Extension lines sideward can be used for adding
radical neck dissection.
B
Role of Radiotherapy in Laryngeal Cancer
In early growth with no impairment in motility curative RT
is very useful with 90% cure rate with preservation of voice
It is commonly used in superficial exophytic lesions, growth
in tip of epiglottis and aryepiglottic folds.
In subglottic extension, fixed growths, and in presence of
nodes, radiotherapy is less effective.
Conservative laryngeal surgery
T
Indications Advantages
• Early growth without fixation
especially glottic type
Types Disadvantages
• Cordectomy through
laryngofissure–excision of
vocal cord after splitting of
larynx
• Permanent tracheostomy is
avoided
• Voice is retained
• Inadequate clearance
• Recurrence of the disease
Contd...
Contd...
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• Partial frontolateral
laryngectomy–excision of
vocal cord and anterior
commissure
• Partial horizontal
laryngectomy–excision of
supraglottis (epiglottis,
aryepiglottic folds, false vocal
cords and ventricle)
Total laryngectomy
T
Indications Technique
Entire larynx with hyoid
• T3 lesions with cord fixation
All T4 lesions
•
•
Bilateral arytenoids spread
Thyroid/cricoid spread
•
Transglottic cancers involving
•
ventricle with fixation of the
cord
•
Posterior commissure
disease
Failure of conservative
•
surgery or RT
• Problems
•
Mortality of surgery
No speech
•
•
Having permanent
tracheostomy and its
problems
CARE AFTER TOTAL LARYNGECTOMY
B
x Speech therapy by pseudoglottis creation, battery operated
artificial larynx or Singer-Blom prosthesis or Panje’s prosthesis.
Tracheo-oesophageal prosthesis (TOP) is ideal
x Social and job rehabilitation
x Care of permanent tracheostomy by avoiding immersion in the
water, care during bath, shower use and swimming. Shower
covers are available for this purpose
x Often along with total laryngectomy, total thyroi dectomy and
removal of parathyroid glands are required. Patient then needs
supplementation of thyroxine and calcium for life time
•
bone, pre-epiglottic space,
strap muscles, one or more
rings of trachea are removed
• Pharyngeal wall is repaired
Lower tracheal stump
•
is sutured to the skin as
permanent tracheostomy
•
Often laryngo-oesopha-
gectomy is done when
pharyngeal spread is present.
Gastric pull-up is done to
maintain GI continuity
•
Technique may be com-
bined with neck nodal
dissection both sides
TRISMUS
It is inability to open the mouth adequately.
Causes are—submucosal fibrosis, carcinoma buccal and
gingivobuccal complex, post-radiotherapy sequelae, infection
like tetanus, parotitis, dental or peritonsillar abscess.
In carcinoma, invasion of tumour to pterygoids, buccinator,
masseter, temporalis causes trismus.
It is often clinically assessed by placing fingers perpendicu-
larly between two jaws at incisor level. More than 3 fingerbreadth is considered as adeguate.
KHANNA AND ANDRADE GROUP CLASSIFICATION OF
B
TRISMUS (1995)
x Group I: Earliest stage without limitation of mouth opening with
an interincisal distance of greater than 35 mm.
x Group II: Patients with an interincisal distance of 26–35 mm.
x Group III: Moderately advanced cases with an interincisal distance
of 15–26 mm. Fibrotic bands are visible at the soft palate, and
pterygomandibular raphe and anterior pillars of fauces are present.
x Group IVA: Trismus is severe, with an interincisal distance of
less than 15 mm and extensive fibrosis of all the oral mucosa.
x Group IVB: Disease is most advanced, with premalignant and
malignant changes throughout the mucosa.
Problems with trismus are—inability to put fingers or spoon
into mouth; difficulty in cleaning the mouth; infection; difficulty in assessing the tumour/pathology clinically. During
surgery, intubation is difficult and so tracheostomy may be
needed in these patients.
Management—treating the cause; release of soft tissue in
case of fibrosis; draining the abscess and antibiotics for
infection.
391
CHAPTER 3 Oral Cavity
A
Figs. 3.88A and B: Endoscopic and Indirect laryngoscopy view of
vocal cords, pyriform fossa and aryepiglottic fold.
B
Fig. 3.89: Trismus due to advanced carcinoma cheek. Patient is on
chemotherapy so developed alopecia.
The road to success is paved with good intentions.
Chapter
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4
Salivary Glands
(Three weeks after arriving at the anatomy laboratory of Gerhard Blasius in Amsterdam) fortune so favoured me that in the
first sheep’s head, which I…was dissecting alone in my room, I found a duct which, so far as I knew, had been described by
no one before.
—Niels Stensen, 1661
C hapter Outline
·
Anatomy
·
Saliva
·
Sialography
·
Salivary Calculus and
Sialadenitis
·
Parotid Abscess
·
Parotid Fistula
·
Recurrent Childhood
Parotitis
·
Sjögren’s Syndrome
·
Sialosis
·
Sialectasis
·
Salivary Neoplasms
·
Pleomorphic Adenoma
·
Adenolymphoma
·
Oncocytoma
·
Basal Cell Adenoma
·
Mucoepidermoid
Tumour
·
Adenoid Cystic Carcinoma
ANATOMY
Parotid Gland (Para—around, otis—ear)
It is the 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 (parotid
capsule) to enclose the gland. The superficial layer is thickened
and adherent to the gland.
·
Acinic Cell Tumour
·
Malignant Mixed
Tumour
·
Adenocarcinoma of
Salivary Glands
·
Squamous Cell
Carcinoma of Salivary
Glands
·
Submandibular Salivary
Gland Tumours
·
Management of
Malignant Salivary
Tumours
·
Minor Salivary Gland
Tumours
·
Parotid Lymphoma
·
Parotidectomy
·
Frey’s Syndrome
·
Facial Nerve Injury
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, parotid fascia stretches and swelling
may become less prominent but this test is difficult to elicit.
When patient clinches his teeth, masseter contracts and parotid
becomes more prominent.
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.
Accessory Parotid
It is prolongation of the gland above the parotid duct (socia
parotidis).
Parotid Duct
Parotid (Stensen’s) duct is 2-3 mm in diameter, 5 cm in length,
emerges from anterior surface of the gland, runs over the surface
of the masseter muscle, passes through the buccinator muscle,
and opens into the oral mucosa opposite to the crown of upper
second molar tooth. It is palpated bidigitally, one fingerbreadth
below the zygomatic bone with index finger inside and thumb
outside, in front of masseter which is felt during clinching of
teeth. Transverse facial artery is above the parotid duct. Duct is
1 cm below the zygomatic arch.
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, later
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dividing into 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
(auricularis anterior and superior part of frontalis), zygomatic
(frontalis and orbicularis oculi), upper buccal and lower buccal
(buccinator, orbicularis oris, elevators of the lip) mandibular
(lower lip muscles) and cervical (platysma).
While exiting the skull through stylomastoid foramen (it is
accompanied by stylomastoid branch of posterior auricular
artery which enters the same 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.
Gland is often called as parotid sandwich due to transverse
of facial nerve.
Blood Supply
It is from external carotid artery; and venous drainage is by
external jugular vein.
Nerve Supply
393
CHAPTER 4 Salivary Glands
Fig. 4.2: Anatomical relations of the parotid gland.
It is from autonomic nervous system, parasympathetic is
secretomotor from auriculo
vasomotor from plexus around the external carotid artery.
tem poral nerve, sympathetic is
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.
Fig. 4.1: Superficial lobe (80%) and deep lobe (20%) are separated
by external carotid artery, retromandibular vein and facial nerve from
deep to superficial.
Fig. 4.3: Pes anserinus.
Lymphatic Drainage of Parotid
It drains into parotid lymph glands which are partly intra glandular
and partly extraglandular (preauricular and infra-auricular).
Mainly intraglandular nodes are involved which later drains into
deep cervical lymph glands. Parotid lymph nodes also drain from
temple, side of scalp, lateral part of auricle, external acoustic
meatus, upper part of cheek, parts of eyelids and orbit.
STRUCTURES WITHIN THE PAROTID GLAND FROM DEEP
B
TO SUPERFICIAL
x External carotid artery, maxillary artery, superficial temporal
artery, posterior auricular artery
x Retromandibular vein (by maxillary and superficial temporal
veins)
x Facial nerve with its branches
Both over-salivation and under-salivation are not advised. Only optimum salivation is accepted and ideal.
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SRB's Manual of Surgery
Fig. 4.4: Vascular plane of parotid.
Great auricular nerve (cutaneous sensory around angle and
lower part of the ear lobule) and auriculotemporal nerve which
is from mandibular division of trigeminal nerve (secretomotor
to parotid gland) are other nerves present in relation to parotid
gland.
Submandibular Salivary Gland
It is a ‘J’ shaped salivary gland situated in the anterior part of
the digastric triangle.
Fig. 4.5: Anatomical relations of the submandibular
salivary gland.
Parts
Superficial part: Lies in submandibular triangle, superficial to
mylohyoid and hyoglossus muscles, between the two bellies
of digastric muscle.
Deep part is in the floor of the mouth and deep to the mylo-
hyoid.
Submandibular (Wharton’s) duct (5 cm), emerges from the
anterior end of the deep part of the gland, enters the floor
A
B
Figs. 4.6A and B: Relations of the submandibular
salivary gland and its deep lobe.
of the mouth, on the summit of papilla beside the frenulum
of the tongue.
Lingual nerve and submandibular ganglion are attached to
upper pole of the gland. Hypoglossal nerve is deep to the gland.
Facial artery emerges from under surface of the stylohyoid
muscle, enters the gland from posterior and deep surface,
reaching its lateral surface crossing the lower border of
mandible to enter the face.
Venous drainage is to anterior facial vein.
Nerve supply: Branches from the submandibular ganglion.
Resting salivary flow usually arises from the submandibular
salivary gland. Sialorrhoea is increased salivary flow often
seen due to drugs, in cerebral palsy, physically handicapped
person, children, and psychiatry patients. Intractable sialorrhoea can be corrected by different surgeries to submandibular salivary gland like duct repositioning to excision of
the gland.
Xerostomia is decreased salivary flow. It is seen in post-
menopausal women, depression, dehydration, use of antidepressant drugs; anticholinergic drugs, Sjogren’s syndrome,
radiotherapy to head and neck region.
Sublingual Salivary Gland
It is a major salivary gland. Sublingual glands are one on each
side; located in the anterior aspect of the floor of the mouth in
relation to mucosa, mylohyoid muscle, body of the mandible
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near mental symphysis. Gland drains directly into mucosa or
through a duct which drains into submandibular duct. This duct
is called as Bartholin duct. The sublingual glands are drained by
8-20 excretory ducts called the ducts of Rivinus; largest one,
the sublingual duct of Bartholin joins the submandibular salivary
gland duct to drain through the sublingual caruncle. Ranula
commonly arises from sublingual salivary gland. Tumours
are rare; but almost all tumours when develop are likely to be
malignant (>90%). They present as hard swelling often nodular
in the floor of the mouth, initially mobile but later get extended
into adjacent structures.
Incision/punch biopsy with
Cervical lymph nodes can get involved.
CT head and neck is the assessment
methods. En block wide excision of the tumour with sublingual
and submandibular salivary gland with mucosa, adjacent structures is the treatment of choice. Radical neck dissection is added;
adjuvant chemotherapy or radiotherapy is required.
Minor Salivary Glands
There are around 800 minor salivary glands which are distributed
in lips, cheeks, palate and floor of the mouth. Glands also may be
present in oropharynx, larynx, trachea and paranasal sinuses. They
contribute to 10% of total salivary volume. Minor salivary glands
are not present in gingivae and anterior portion of the hard palate.
SIALOGRAPHY
Sialography (Arcelin, 1913, did first using bismuth for submandibular salivary gland stone disease) is rarely done nowadays.
Fig. 4.7: Sialogram X-ray done to visualise
the ductal pattern in parotid.
395
CHAPTER 4 Salivary Glands
Ectopic Salivary Glands
Ectopic salivary gland also called as aberrant salivary gland is
nothing but ectopic lobe of the juxtaposed salivary gland. It is
commonly seen in relation to submandibular salivary gland.
Commonest ectopic salivary tissue is Stafne bone cyst
(Edward
C Stafne, Dental Surgeon, Mayo Clinic). It is invagination of the juxtaposed submandibular salivary gland into
the mandible bone on its lingual aspect.
X-ray shows radiolucent area due to the cyst below the angle
of the mandible, lower to inferior dental vessels and nerve.
SALIVA
1500 ml of saliva is secreted per day. pH of resting saliva is
less, 7.0; active saliva is 8.0.
Saliva contains lingual lipase secreted from tongue glands,
α amylase from salivary glands.
Saliva contains mucin, glycoproteins, immunoglobulin IgA,
lysozyme, lactoferrin which binds iron, proline rich proteins
that protect enamel and bind toxic tannins.
Parotid saliva is 20% of total secretion of saliva per day and
is serous and watery; submandibular is 70% and is mucous
and moderately viscous; sublingual is 5% and is mucous and
viscous. Minor salivary and other oral glands—5%.
Saliva facilitates swallowing, keeps mouth moist, serves as
solvent for taste buds, facilitates speech, keeps oral cavity
rinsed and clean, antibacterial, and neutralizes gastric acid
content in regurgitation to relieve heartburn.
Fig. 4.8: Submandibular gland sialogram pictures (Courtesy: Professor
Kishore
Dr Sampath, MS ENT, KM
Chandra Prasad, ENT surgeon and HOD, KMC, Mangaluru;
C, Mangaluru).
Indications: Sialectasis, salivary fistula, Sjögren’s syndrome,
congenital conditions, extraglandular masses. It is done for
parotid and submandibular salivary gland imaging. Sialography cannot be done for sublingual salivary gland imaging
as its Bartholin’s duct is too smaller in diameter.
Technique: Patient should rinse the mouth with water prior
to Sialography; all dentures should be removed; preliminary
plain X-ray should be taken to identify existing stones. Duct
is identified at its location; if difficulty arises in identifying the
duct then lime piece is placed on the tongue and pressure
is applied on the gland to allow adequate salivary flow. Duct
orifice can be widened using lacrimal dilator; fine polythene
cannula (24 gauge) or lacrimal cannula is passed into the
orifice. Not more than 1 mL of water soluble iodine dye like
sodium diatrizoate is injected (lipiodol was used in olden
days) gently. For parotid gland anteroposterior view X-ray
with face rotated 10° towards the side with additional lateral
view with 20° cranial tilt films are taken; but deep lobe of the
parotid cannot be seen. For submandibular salivary gland
lateral film with 20° cranial tilt X-ray film is used. Once
adequacy of imaging is got, cannula is removed; antibiotics
and anti-inflammatory drugs should be given to avoid sialadenitis. Digital subtraction Sialography is better in Sjögren’s
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