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Examination of Salivary Gland
https://t.me/med1917
Fig. 12.16: Submandibular salivary gland duct should
be palpated per orally.
281
Differential Diagnosis for Parotid Enlargement
Idiopathic hypertrophy of masseter muscle: It is a rare
entity but presents like a swelling. When teeth are
clenched entire swelling hardens; but when relaxed
swelling softens. It often can be bilateral.
Preauricular lymph node enlargement: Swelling lies
in front of the tragus; normal depression below and
in front of the ear lobule is not obliterated; it may
be suppuration, adenitis, tuberculosis or lymphoma.
It feels more superficial.
Rarely parotid and paraparotid/subparotid lymph
nodes may be enlarged as secondaries from primary
oral mucosa and skin malignancies of head and neck
region (but these things are very rare and so students
should not consider in usual clinical practice unless
it is relevant). Still rarely parotid gland may be enlarged
as nonmetastatic obstruction of the duct by carcinoma
cheek.
Differential Diagnosis for Submandibular
Salivary Gland Enlargement
Enlarged submandibular lymph nodes: Bidigital palpation helps to confirm it. Lymph nodes are not
bidigitally palpable.
Fig. 12.17: Mandible should be palpated bidigitally for
relation of tumour, thickening, and tenderness.
Palpation
Tenderness / temperature / extent / size / surface /
consistency / mobility / fixity / plane of the swelling /
masseter involvement / facial nerve involvement / skin
over the swelling.
Parotid duct palpation—by rolling the finger across the
masseter muscle while patient is clinching the teeth to
make masseter taut. Terminal part of the duct is palpated
bidigitally using index finger inside and thumb outside.
Palpation of oral cavity / bidigital examination for deep
lobe is done with one finger inside the mouth behind
the tonsillar fossa and the other outside in parotid region.
All features of facial nerve palsy—inability to close eye/
difficulty in blowing / altered nasolabial groove / clinching
of teeth.
Neck nodes should be examined.
Examination of other salivary glands should be done.
Relevant findings should be elicited in case of
submandibular salivary gland enlargement .
Enlarged facial lymph node lies adjacent to facial artery
at the lower margin of the mandible which can be
moved above the level of the margin of the mandible
into the face.
Functions of facial nerve should be checked. It
is involved in malignant growth where nerve is
infiltrated. It is involved early in adenoid cystic
carcinoma; carcinoma ex pleomorphic adenoma. It
is involved late in mucoepidermoid carcinoma.
Patient finds difficulty in closing eyes (orbicularis
oculi); eye contains tear which does not fall; difficulty
in chewing food (buccinator); difficulty in talking,
laughing, blowing, and whistling (orbicularis oris).
Upper face:
Orbicularis oculi: Patient may not be able to open
his eyes. In facial nerve paralysis eyes can be easily
opened by the examiner when patient closes his eyes
tightly .
Frontal belly of occipitofrontalis: Absence of
furrowing in the forehead while looking upwards.
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SRB’s Clinical Surgery
Corrugator supercilii: Absence of corrugation in the
forehead while frowning.
Lower face:
Buccinator: While blowing with mouth closed, tone
can be felt in the cheek.
Orbicularis oris: Inability to whistle.
Levator anguli oris: Deviation of angle of mouth
towards opposite side while showing teeth.
Platysma: Loss of normal contraction while stretching
the neck.
In supranuclear (upper motor neuron lesion)
paralysis upper face escapes due to bilateral cortical
representation.
Taste sensation and general sensation (lingual
nerve) should be checked. Patient is not allowed to
speak but asked to write in a paper. Taste material
is instilled on the surface of the diseased side first
and then normal side. Prior to each instillation patient
should wash his mouth with warm water. Usually four
substances are used. After 10 seconds patient should
identify the substance and write. Facial nerve serves
3 tastes—salt (rock salt) on the tip of tongue; sweet
using sugar syrup on the tip of the tongue; sour using
lemon juice on the lateral aspect of the tongue. Bitter
taste is mediated by glossopharyngeal nerve and is
tested using quinine on posterior third of the tongue.
Hypoglossal nerve function is checked by asking
the patient to protrude the tongue out and observe
the deviation of tongue. Accessory nerve function is
assessed by asking the patient to shrug the shoulder,
done in cases of enlarged upper deep cervical nodes
infiltrating the nerve and paralysing the trapezius
(Fig. 12.18).
Palpation of superficial temporal artery pulsation
should be done in front of the tragus over the zygomatic
bone.
Palpation of cervical nodes for significant enlargement should be done (Figs 12.19A and B). Features
of Horner’s syndrome should also be looked for in
specific patients (Fig. 12.20).
Fig. 12.18: Hypoglossal nerve should be assessed in
submandibular salivary gland enlargement.
A
B
Figs 12.19 A and B: Palpation of neck nodes in a patient with
parotid swelling – submandibular and upper deep cervical.
Examination of Salivary Gland
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Fig. 12.20: Cervical nodes should be palpated in
submandibular salivary gland enlargement.
Features of facial nerve palsy
• Difficulty in chewing food as food accumulates in
vestibule due to buccinator weakness (Fig. 12.21)
• Deviation of angle of mouth while talking, laughing,
283
Fig. 12.21: Facial nerve palsy – typical look.
(Fig. 12.22)
• Failure of closure of eyelids or easily opening of the
eyelids after closure—paralysis of orbicularis oculi (Figs
12.23A to C)
• Absence of furrows while looking upwards—paralysis
of frontal belly of occipitofrontalis
• Absence of corrugation in the forehead during
frowning—paralysis of corrugator supercilii (Fig. 12.24)
• Deviation of angle of mouth towards opposite side—
paralysis of levator anguli oris (Fig. 12.25)
• Loss of contraction of platysma in the neck while
stretching the neck—paralysis of platysma (Fig. 12.26)
• Inability to blow the air by the check and on palpation
reduced tone of buccinator—paralysis of buccinator
• Inability to whistle—paralysis of orbicularis oris
Proper diagnosis and investigations should be
mentioned.
Investigations
X-ray of the part often intraoral X-ray to look for
radiopaque stone in the submandibular region (Fig.
12.27).
Fig. 12.22: Inability to whistle – paralysis of orbicularis oris.
CT scan of the part including neck to see extent
of the tumour, deep lobe involvement, and adjacent
spread (Fig. 12.28).
FNAC of the swelling.
Sialography
Indications: Salivary fistulas; Sialectasis; Congenital
conditions; Extraglandular masses. Dye used is
Lipiodol or sodium diatrizoate (Hypaque). 24-gauge
cannula is passed into either the Stensen’s duct or
Wharton’s duct and 1 ml of the dye is injected and
X-ray is taken.
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A
SRB’s Clinical Surgery
Fig. 12.24: Absence of corrugation in the forehead
during frowning – paralysis of corrugator supercilii.
B
C
Figs 12.23A to C: Failure of closure of eyelids or easily
opening of the eyelids after closure – paralysis of orbicularis
oculi.
Fig. 12.25: Deviation of angle of mouth towards opposite
side while clenching the teeth – paralysis of levator anguli
oris.
Fig. 12.26: Loss of contraction of platysma in the neck
while stretching the neck – paralysis of platysma.
Examination of Salivary Gland
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285
Fig. 12.27: Plain X-ray showing submandibular salivary gland
stone – radioopaque. (Courtesy by Dr Jagadishchandra MDS
Mangalore).
Fig. 12.28: CT scan of pleomorphic adenoma.
Findings: Narrowing (stricture); grape-like cluster
appearance (sialectasis); dilatations; communications
(Fistulas); mass lesions. Sialography should never be
performed in acute inflammation. Only one ml of dye
is injected, if more dye is injected it causes extravasa-
tion and chemical sialadenitis (Figs 12.29A and B).
Salivary Neoplasms
Classification
a. Epithelial:
1. Adenomas
- Pleomorphic adenoma.
A
B
Figs 12.29A and B: Sialogram of parotid and
submandibular salivary glands.
- Monomorphic adenomas.
• Adenolymphoma (Warthin’s tumour).
• Oxyphil adenomas, oncocytoma.
• Basal cell adenoma.
2. Carcinomas
- Mucoepidermoid carcinoma—Commonest
malignancy.
- Acinic cell carcinoma 1%.
- Adenoid cystic carcinoma—Very aggressive.
- Adenocarcinoma.
- Squamous cell carcinoma - 2%.
- Carcinoma in ex. pleomorphic adenoma.
- Undifferentiated carcinoma.
b. Nonepithelial:
• Haemangioma—commonly seen in infants,
usually in parotids. Spontaneous regression is
common.
• Lymphangioma:
• Neurofibromas and neurilemmomas.
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SRB’s Clinical Surgery
c. Malignant lymphomas—Common in parotid;
NHL type.
d. Secondary tumours from head, neck region;
bronchus and skin.
e. Lymphoepithelial tumours—Benign type (5%) is
common in females; can be bilateral (Godwin’s
tumour). Malignant is rare tumour—occurs in parotid and submandibular salivary glands (Eskimoma).
Incidence
75-80% salivary neoplasms are in the parotids of which
80% are benign; 80% of these are pleomorphic adenomas. 15% of salivary tumours are in the submandibular
salivary gland; of which 60% are benign; 95% of these
are pleomorphic adenomas. 10% of salivary neoplasms
are in the minor salivary glands—palate, lips, cheeks
and sublingual glands. Of these only 10% are benign
(Fig. 12.30).
parotid tumour often begins in front of the tragus. It
is mesenchymal, myoepithelial and duct reserve cell
origin. Grossly it contains cartilages, cystic spaces,
and solid tissues. Histologically it shows—Epithelial
cells; myoepithelial cells; mucoid material with
myxomatous changes; cartilages. Even though it is
capsulated, tumour may come out as pseudopods and
may extend beyond the main limit of the tumour tissue.
When disease occurs in parotid, often it involves
superficial lobe or superficial and deep lobe together
(Fig. 12.31). But sometimes only deep lobe is involved
where it presents as swelling in the lateral wall of
the pharynx, soft palate and posterior pillar of the
fauces. There may not be any visible swelling in the
preauricular region—Dumb bell tumour. This tumour
is in relation to styloid process, mandible, stylohyoid,
styloglossus, stylopharyngeus muscles.
Fig. 12.30: Parotid gland enlargement in young boy.
Note: Parotid tumours are common but only 20% are
malignant. Submandibular tumours are uncommon and
50% of them are malignant. Minor salivary gland
tumours (other than sublingual glands) are rare and
90% of them are malignant. Sublingual salivary
tumours are very rare but almost all sublingual salivary
tumours are malignant.
Pleomorphic Adenomas
(Mixed Salivary Tumour)
It is the commonest of the salivary gland tumour. It
is 80% common. It is more common in parotids. Mixed
Fig. 12.31: Raised ear lobule is important sign of
parotid enlargement.
Clinical Features
1:1 male to female ratio; 80% common; occurs in any
age group; usually unilateral. Present as a single
painless, smooth, firm lobulated, mobile swelling in
front of the parotid with positive curtain sign (As the
deep fascia is attached above to the zygomatic bone,
it acts as a curtain, not allowing the parotid swelling
to move above that level. Any swelling superficial
to the deep fascia will move above the zygomatic bone).
The ear lobule is lifted. When deep lobe is involved,
swelling is commonly located in the lateral wall of
pharynx, posterior pillar and over the soft palate. Facial
nerve is not involved.
Examination of Salivary Gland
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Long standing pleomorphic adenoma may turn into
carcinoma – (carcinoma in ex. pleomorphic adenoma).
Its features are: Recent increase in size; pain and nodularity; involvement of skin; involvement of masseter;
involvement of facial nerve—lower facial nerve palsy;
involvement of neck lymph node. Recurrence of
pleomorphic adenoma is 5-40%; it is more if enucleated
but less if parotidectomy is done. Malignant
transformation is 3-5%; it may be 10% in long standing
(15 years or more) pleomorphic adenomas.
Investigations
FNAC is very important and diagnostic. CT scan to
know the status of deep lobe. Incision biopsy of parotid
is contraindicated as there is chance of seedling of
tumour and also injuring the facial nerve.
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Adenolymphoma (Warthin’s Tumour, Papillary
cystadenolymphomatosum)
It is a benign tumour that occurs only in parotid, usually
in the lower pole / near angle of the mandible; common
in males; it is often bilateral – 10%; It is said to be
due to trapping of jugular lymph sacs in parotid during
developmental period. It is composed of double layered
Fig. 12.32: Location of Warthin’s adenolymphoma.
Investigations
Adenolymphoma produces a ‘hot spot’ in 99Technetium pertechnetate scan - it is diagnostic. FNAC.
Adenolymphoma does not turn into malignancy.
of columnar epithelium, with papillary projections into
cystic spaces with lymphoid tissues in the stroma (Fig.
12.32).
Mucoepidermoid Tumour
It is the commonest malignant salivary gland tumour
(in major salivary glands). It is slowly progressive,
Clinical Features
It presents as a slow growing, smooth, soft, cystic,
fluctuant swelling, in the lower pole, often bilateral
and nontender. It is common in males (4:1). It is not
seen in Negroes. It is 10% common in old people
– 60 years.
TNM staging of malignant salivary tumours
T — Tumour N — Lymph node
TX — Tumour cannot be assessed Nx — Nodes not assessed
T0 — No evidence of primary tumour N0 — Regional nodes not involved
T1 — Tumour < 2 cm without extraparenchymal spread N1 — Single ipsilateral node < 3 cm
T2 — Tumour 2-4 cm N2a — Single ipsilateral node 3-6 cm
T3 — Tumour 4-6 cm N2b — Multiple ipsilateral nodes < 6 cm
— or with extraparenchymal spread N2c — Bilateral or contralateral nodes < 6 cm
— but no facial nerve spread N3 — Single node spread > 6 cm.
T4 — Tumour > 6 cm
— or facial nerve spread M — Metastases
— or base of skull spread. M0 — No blood spread
often attains a large size and spreads to neck lymph
nodes. It contains malignant epidermoid and mucus
secreting cells.
Types: Low grade and High grade. Facial nerve
involvement is rare or very late in mucoepidermoid
carcinoma of parotid.
M1 — Blood spread present.
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SRB’s Clinical Surgery
Clinical features: Swelling in the salivary (parotid
or submandibular) region, slowly increasing in size,
eventually attaining a large size, which is hard, nodular,
often with involvement of skin and lymph nodes.
Adenoid Cystic Carcinoma
(10% of Salivary Tumours)
It is common in minor salivary glands. It consists of
myoepithelial cells and duct epithelial cells with cribriform or lace-like appearance. It involves facial nerve
very early , spreads through the perineural sheath over
a long distance more proximally and infiltrates into
the perineural tissues and bone marrow. It also invades
periosteum and bone medulla early and spreads
extensively. It carries poor prognosis.
Acinic Cell Tumour
It is a rare, slow growing tumour that occurs almost
always in parotid and is composed of cells alike serous
acini. It is more common in women. It occurs in
adult and elderly. It can involve facial nerve or neck
lymph nodes. Clinically it is of variable consistency
with soft and cystic areas. It is low grade malignant
tumour.
GENERAL FEATURES OF MALIGNANT SALIVARY
TUMOURS:
• Fixation, resorption of adjacent bone, pain and
anaesthesia in the skin and mucosa
• Muscle paralysis, skin involvement and nodularity
• Involvement of jaw and masticatory muscle
• Nerve involvement (facial nerve in parotid or
hypoglossal nerve in submandibular salivary gland)
• Mandibular branch of 5th cranial nerve may be involved
when tumour tracks along the auriculotemporal nerve
to the base of the skull causing severe pain in the
distribution area
• Blood spread to lungs can occur
Vernet syndrome: It is due to compression at jugular
foramen and results in 9th, 10th and 11th nerves.
Collet-Sicard syndrome: It is due to compression at
posterior condylar space causing 9th, 10th, 11th and
12th nerve palsies.
Submandibular Salivary Gland Tumours
Benign Tumours
Benign tumours commonly pleomorphic adenomas
are smooth, firm or hard, bidigitally palpable, without
involving adjacent muscles or hypoglossal nerve or
mandible bone. Diagnosis is by FNAC, Orthopantomogram and CT scan.
Malignant Tumours
Malignant tumours of submandibular salivary gland:
They are hard, nodular, often get fixed to skin, muscles,
hypoglossal nerve, and mandible. Diagnosis is by
FNAC of primary tumour and of lymph nodes when
involved, CT scan and OPG.
Specific Investigations
FNAC; CT scan to look for the involvement of deep
lobe of the parotid; look for the involvement of bone,
extension into the base of the skull, relation of tumour
to internal carotid artery, styloid process, etc. (Fig.
12.33). OPG; Blood grouping and cross matching;
Clinical Syndromes Related to Involvement of
Base of Skull in Malignant Parotid Tumour
Villaret-Mackenzie-Tapia syndrome of posterior
retroparotid space: It is due to compression of the
9th to 12th cranial nerves and cervical sympathetic
chain at the base of skull. There is dysphagia; dyspnoea;
salivation changes; taste changes; weakness of
trapezius, sternomastoid, same side tongue and soft
palate; Horner’s syndrome.
Fig. 12.33: Submandibular salivary gland tumour. Here oral
cavity should be examined for deep lobe (bidigitally with
one finger in the floor of the mouth); Wharton’s duct (on
either side of the frenulum of tongue); mandibular bone for
thickening; hypoglossal nerve and lingual nerve palsy; neck
nodes for spread.
Examination of Salivary Gland
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required amount of blood is keep ready. FNAC of
lymph node; MRI shows better soft tissue definition
than CT scan. Sialogram is not useful in assessment
of tumour.
Minor Salivary Gland Tumours
It is 10% of salivary tumours. It is common in—palate
(40%); lip; cheek; sublingual glands. Palate is the
commonest site (Fig. 12.34). 10% are benign—com-
monly pleomorphic adenomas. 90% are malignant—
commonly adenoid cystic carcinomas. They present
as swelling with ulcer over the summit. If it is malignant,
then extension into the palate, maxilla, pterygoids can
occur often with involvement of lymph node.
Fig. 12.34: Minor salivary gland tumour in the palate.
Palate is the commonest site.
Differential diagnosis: Squamous cell carcinoma of
oral cavity.
Investigations: Incision biopsy; CT Scan; X-ray
maxilla; FNAC of lymph node.
Salivary gland tumours are usually benign in adult.
It is rare in children but when it occurs, it is commonly
malignant.
Clinical and FNAC are diagnostic methods.
Open biopsy is contraindicated.
Sialogram is not useful in salivary tumours.
CT or MRI are often needed.
Nerve should be preserved in benign lesions.
Nerve can be sacrificed to achieve clearance in
malignancies.
289
Parotid Lymphoma
Parotid lymphoma can occur from the lymph nodes
in the gland or from parotid parenchyma. It can occur
in HIV patients; lymphoepithelial diseases and in
Sjogren’s syndrome. It is common in elderly . Disease
may be confined to parotid gland or may involve other
nodes in neck, mediastinum. 90% of salivary lymphomas occur in parotid. When it is confined to parotid
total parotidectomy with radiotherapy and later
chemotherapy is the treatment. When many other nodes
are involved chemotherapy is the choice of therapy.
Note: Lymphoma occasionally can occur in other
salivary glands also (10% of all salivary lymphomas).
Complications of Surgery
Haemorrhage; infection; fistula; Frey’s syndrome;
facial nerve palsy; facial numbness; numbness in
ear lobule due to injury to great auricular nerve;
sialocele.
syndrome; gustatory sweating [Lucie
Frey—Polish surgeon 1932])
It occurs in 10% of cases. It is due to injury to the
auriculotemporal nerve, where in post ganglionic
parasympathetic fibres from the otic ganglion become
united to sympathetic nerves from the superior cervical
ganglion (Pseudosynapsis). Auriculotemporal nerve
has got two branches. Auricular branch supplies exter nal acoustic meatus, surface of tympanic membrane,
skin of auricle above external acoustic meatus.
Temporal branch supplies hairy skin of the temple.
Sweating and hyperesthesia occurs in this area of skin.
Causes: (1) Surgeries or accidental injuries to the
parotid. (2) Surgeries or accidental injuries to temporomandibular joint.
Features: Flushing, sweating, pain and hyperaesthesia
in the skin over the face innervated by the auriculotemporal nerve, whenever salivation is stimulated
(i.e. during mastication). Condition causes real
inconvenience to the patient. Starch iodine test
will show the area blue (involved skin is painted with
iodine and dried; dry starch applied over this area
will turn blue due to more sweat in the area in Frey’s
syndrome).
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Salivary Calculus and Sialadenitis
SRB’s Clinical Surgery
80% are in submandibular; 80% are radio-opaque; it
is commonly calcium phosphate and calcium carbonate
stones. Calculi in submandibular gland is more common, because the gland secretion is viscous, contains
more calcium and also its drainage is nondependent,
causing stasis. Secretion from parotid is serous,
contains less calcium and so stones are not common.
Presentation
Acute features: Pain, swelling, tenderness is seen in
submandibular region and floor of the mouth; Duct
is inflamed and swollen. Features in chronic cases:
Pain is more during mastication due to stimulation.
Salivary secretion is more during mastication causing
increase in gland size. Firm, tender swelling is palpable
bidigitally. When stone is in the duct, it is palpable
in the floor of the mouth as a tender swelling with
features of inflammation in the duct. Pus exudes
through the duct orifice. In submandibular salivary
gland, the stones are multiple, with inflammation of
gland (sialadenitis) (Fig. 12.35).
A
Submandibular lymphadenitis; salivary neoplasm.
Investigations
Intraoral X-ray (dental occlusion films) to see radio
opaque stones (Figs 12.36A and B); FNAC of the
gland to rule out other pathology; Total count and
ESR in acute phase.
Fig. 12.35: Submandibular sialadenitis.
B
Figs 12.36A and B: Submandibular salivary stone in
the duct and radioopaque shadow in X-ray.
Salivary calculi in Salivary calculi in
submandibular gland parotid gland
80% common 20% incidence (Rare)
80% Radio-opaque Radiolucent
Seen in plain X-ray (intraoral) Not seen in plain X-ray
Sialogram is not needed Identified by sialogram
Calculi are common in submandibular salivary gland,
because—
• Viscous nature and mucin content
• Calcium content
• Non dependent drainage
• Stasis.
Sialosis
It is enlargement of the salivary gland due to fatty
infiltration as a result of various metabolic causes like
diabetes, acromegaly, obesity, liver disease. Clinical
features: Bilateral diffuse enlargement of parotids,
which is smooth, firm, nontender.
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