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20 Diagnosis and Management of Salivary Gland Disorders Diagnosis and Management of Salivary Gland Disorders Michael Miloro and Sterling R. Schow CHAPTER CHAPTER OUTLINE EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY OBSTRUCTIVE SALIVARY GLAND DISEASE DIAGNOSTIC MODALITIES Sialolithiasis History and Clinical Examination Salivary Gland MUCOUS RETENTION AND EXTRAVASATION Radiology Plain Film Radiographs Sialography PHENOMENA Computed Tomography, Magnetic Resonance Mucocele Imaging, and Ultrasound Ranula Salivary Scintigraphy (Radioactive Isotope SALIVARY GLAND INFECTIONS Scanning) NECROTIZING SIALOMETAPLASIA SJOGREN'S SYNDROME Salivary Gland Endoscopy (Sialoendoscopy) TRAUMATIC SALIVARY GLAND INJURIES Sialochernistry NEOPLASTIC SALIVARY GLAND DISORDERS Fine-Needle Aspiration Biopsy Benign Salivary Gland Tumors Salivary Gland Biopsy Malignant Salivary Gland Tumors he clinician is frequently confronted with EMBRYOLOGY, ANATOMY, AND PHYSIOLOG the necessity of assessing and The salivary glands can be divided into two groups: managing salivary gland disorders. A the minor and major glands. All salivary glands develop thorough knowledge of the embryology, anatomy, and from the embryonic oral cavity as buds of pathophysiology is necessary to treat patients epithelium that extend into the underlying appropriately. This chapter examines the cause, mesenchymal tissues. The epithelial ingrowths diagnostic methodology, radiographic evaluation, and branch to form a primitive ductal system that management of a variety of salivary gland disorders, eventually becomes canalized to provide for drainage including sialolithiasis and obstructive phenomena of salivary secretions. The minor salivary glands begin (e.g., mucocele and ranula), acute and chronic to develop around the fortieth day in utero, where- as salivary gland infections, traumatic salivary gland the larger major glands begin to develop slightly earli- disorders, S]6gren's syndrome (SS), necrotizing er, at about the thirty-fifth day in utero. At around sialometaplasia, and benign and malignant salivary the seventh or eighth month in utero, secretory cells gland tumors. called 434 Diagnosis and Management of Salivary Gland Disorders CHAPTER 20 435 FIG. 20-1 Parotid gland anatomy. The course of Stensen's duct runs super- ficial to the masseter muscie and then curves sharply anteriorly to pierce the buccinator muscle fibers and enter the oral cavity. acini begin to develop around the ductal system. The aci- ed into three groups: (1) inferior apical (glands of Blandin nar cells of the salivary glands are classified as either Nuhn), (2) taste buds (Ebner's glands), and (3) posterior serous cells, which produce a thin, watery serous secre- lubricating glands (Table 20-1). tion, or mucous cells, which produce a thicker, viscous The parotid glands, the largest salivary glands, lie mucous secretion. The minor salivary glands are well superficial to the posterior aspect of the masseter muscle developed and functional in the newborn infant. The and the ascending ramus of the mandible. Peripheral por- acini of the minor salivary glands primarily produce tions of the parotid gland extend to the mastoid process, mucous secretions, although some are made up of serous along the anterior aspect of the sternocleidomastoid mus- cells, as well. The major salivary glands are paired struc- cle, and around the posterior border of the mandible into tures and are the parotid, submandibular, and sublingual the pterygomandibular space (Fig. 20-1). The major glands. The parotid glands contain primarily serous acini branches of the seventh cranial (facial) nerve roughly with few mucous cells. Conversely, the sublingual glands divide the parotid gland into a superficial lobe and a deep are for the most part composed of mucous cells. The sub- lobe while coursing anteriorly from their exit at the sty- mandibular glands are mixed glands, made up of approx- lomastoid foramen to innervate the muscles of facial imately equal numbers of serous and mucous acini. expression. Small ducts from various regions of the gland Between 800 and 1000 minor salivary glands are found coalesce at the anterosuperior aspect of the parotid to throughout the portions of the oral cavity that are cov- form Stensen's duct, which is the major duct of the ered by mucous membranes, with a few exceptions, such parotid gland. Stensen's duct is about 1 to 3 mm in diam- as the anterior third of the hard palate, the attached gin- eter and 6 cm in length. giva, and the dorsal surface of the anterior third of the Occasionally, a normal anatomic variation occurs in tongue. The minor salivary glands are referred to as the which an accessory parotid duct may aid Stensen's duct labial, buccal, palatine, tonsillar (Weber's glands), retromo- in drainage of salivary secretions. Additionally, an acces- lar (Carmalt's glands), and lingual glands, which are divid- sory portion of the parotid gland may be present some- 436 PART IV ■ Infections where along the course of Stensen's duct. The duct runs the ninth cranial (glossopharyngeal) nerve via the auric- anteriorly from the gland and is superficial to the mas- lotemporal nerve from the otic ganglion. seter muscle. At the location of the anterior edge of the The submandibular glands are located in the sub- masseter muscle, Stensen's duct turns sharply medial and mandibular triangle of the neck, which is formed by the passes through the fibers of the buccinator muscle. The anterior and posterior bellies of the digastric muscles anc duct opens into the oral cavity through the buccal the inferior border of the mandible (Fig. 20-2). The mucosa, usually adjacent to the maxillary first or second posterosuperior portion of the gland curves upward molar tooth. The parotid gland receives innervation from around the posterior border of the mylohyoid muscle and TABLE 20-1 Salivary Gland Embryology and Anatomy Minor Salivary Glands Major Salivary Glands In utera development Day 40 Day 35 Number 800-1000 6 Types Labial Parotid Buccal Submandibular Palatine Sublingual Tonsillar • Weber's glands Retromolar • Carmalt's glands Lingual • Inferior apical (Glands of Blandin Nuhn) • Taste buds (Ebner's glands) • Posterior lubricating glands Parotid gland V Facial artery and vein Submandibular gland Posterior belly of digastric muscle Myiohyoid muscle Hyoid bone Anterior belly of digastric muscle :FIG. 20-2 Submandibular gland anatomy. The anterior and posterior bellies of the digastric muscles and the inferior border of the mandible form the submandibular triangle. Diagnosis and Management of Salivary Gland Disorders CHAPTER 20 437 gives rise to the major duct of the submandibular gland with parotid gland concentrations generally higher than known as Whartoris duct. This duct passes forward along the submandibular gland, except for submandibular cal- the superior surface of the mylohyoid muscle in the sub- cium concentration, which is approximately twice the lingual space, adjacent to the lingual nerve. The anatomic concentration of parotid calcium (see Table 20-2). The relationship is such that the lingual nerve loops under relative viscosities of saliva vary according to gland and Wharton's duct, from lateral to medial, in the posterior floor of the mouth. Wharton's duct is about 5 cm in length, and the diameter of its lumen is 2 to 4 mm. TABLE 20-2 Wharton's duct opens into the floor of the mouth via a punctum located close to the incisors at the most anteri- Composition of Normal Adult Saliva or aspect of the junction of the lingual frenum and the floor of the mouth. The punctum is a constricted portion Parotid Submandibular of the duct, and it functions to limit retrograde flow of Gfand Gland bacteria-laden oral fluids. This particularly limits those Sodium 23.0 mEq/L 21.0 mEq/L bacteria that tend to colonize around the ductal orifices. The sublingual glands lie on the superior surface of the Potassium 20.0 mEq/L 17.0 mEq/L mylohyoid muscle, in the sublingual space, and are sepa- Chloride 23.0 mEq/L 20.0 mEq/L rated from the oral cavity by a thin layer of oral mucosa Bicarbonate 20.0 mEq/L 18.0 mEq/L (Fig. 20-3). The acinar ducts of the sublingual glands are Calcium 2.0 mEq/L 3.6 mEq/L called Bartholin's ducts and in most instances coalesce to Phosphate 6.0 mEq/L 4.5 mEq/L form 8 to 20 ducts of Rivinus. These ducts of Rivinus are Magnesium 0.2 mEq/L 0.3 mEq/L short and small in diameter. They either open individually Urea 15.0 mg/dl 7.0 mg/dl directly into the anterior floor of the mouth on a crest of Ammonia 0.3 mg/dl 0.2 mg/dl mucosa, known as the plica sublingualis, or they open Uric acid 3.0 mg/dl 2.0 mg/dl indirectly through connections to the submandibular Glucose <1.0 mg/dl <1.0 mg/dl duct and then into the oral cavity via Wharton's duct. Cholesterol < 1.0 mg/dl <1.0 mg/dl The sublingual and submandibular glands are innervated Fatty acids 1.0 mg/dl <1.0 mg/dl by the facial nerve through the submandibular ganglion Amino acids 1.5 mg/dl <1.0 mg/dl via the chorda tympani nerve. Proteins 250.0 mg/dl 150.0 mg/dl The functions of saliva are to provide lubrication for speech and mastication, to produce enzymes for diges- tion, and to produce compounds with antibacterial properties (Table 20-2). The salivary glands produce approximately 1000 to 1500 ml of saliva per day, with the BOX 20-1 highest flow rates occurring during meals. The relative Daily Saliva Production by Salivary Gland contributions of each salivary gland to total daily pro- duction varies, with the submandibular gland providing Submandibular gland 70% 70%, the parotid gland 25%, the sublingual gland 3% to 4%, and the minor salivary glands contributing only Parotid gland 25% trace amounts of saliva (Box 20-1). The electrolyte com- Sublingual gland 3%-4% position of saliva also varies between salivary glands, Minor glands Trace Plica sublinguaiis Lingual nerve Wharton's duct Ducts of Rivinus Submandibular gland Bartholin's ducts' Sublingual gland FIG.
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