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Core Features Embryology of the salivary glands and their as sociated structures Detailed anatomy of the parotid submandibular sublingual and minor salivary glands including nervous innervation art

Christopher Holsinger and Dana T Bui Contents Introduction Developmental Anatomy Parotid Gland Anatomy Fascia

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Core Features Embryology of the salivary glands and their as sociated structures Detailed anatomy of the parotid submandibular sublingual and minor salivary glands including nervous innervation art






Presentation on theme: "Core Features Embryology of the salivary glands and their as sociated structures Detailed anatomy of the parotid submandibular sublingual and minor salivary glands including nervous innervation art"— Presentation transcript:

Chapter Anatomy,Function,andEvaluationoftheSalivaryGlands F. Christopher Holsinger and Dana T. Bui 1 Contents Introduction ..................................... DevelopmentalAnatomy ArterialSupply ................................. VenousDrainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LymphaticDrainage............................ ParapharyngealSpace ........................... SubmandibularGland LymphaticDrainage............................ SublingualGland ................................. MinorSalivaryGlands............................ Histology....................................... PhysiologyofSalivaryGlands theanteriorborderofthegland,ittravelsparalleltothezygoma,approximatelybelowit,ananterior rectionacrossthemassetermuscleItthenturnssharplytopiercethebuccinatormuscleandenterstheoralcavityoppositetheseconduppermolartoothNeuralAnatomyefacialnerveexitstheskullbaseviathesty lomastoidforamen,whichisslightlyposterolateraltothestyloidprocessandanteromedialtothemastoidprocessBeforeenteringtheposteriorportionoftheparotidgland,threemotorbranchesaregivenotoinnervatethepos teriorbellyofthedigastricmuscle,thestylohyoidmuscle,andthepostauricularmusclesemaintrunkofthefacialnervethenpassesthroughtheparotidglandand,atthe pes anserinus(Latin:goose’sfoot),dividesintothetemporofacialandlowercervico facialdivisionsapproximatelyfromthestylomas toidforameneupper temporofacial divisionformsthefrontal,temporal,zygomatic,andbuccalbrancheselower cervicofacial divisionformsthemarginalmandibu larandcervicalbranchesBranchesfromthemajorup perandlowerbranchesoenanastomosetocreatethediversenetworkofmidfacialbuccalbranchese temporal branchtraversesparalleltothesuper cialtemporalvesselsacrossthezygomatosupplythefrontalbellyoftheoccipitofrontalismuscle,theorbicu larisoculi,thecorrugatorsupercilii,andtheanteriorandsuperiorauricularmusclese zygomatic branchtravelsdirectlyovertheperiosteumofthezygomaticarchto nervatethezygomatic,orbital,andinfraorbitalmusclese buccal branchtravelswithStensen’sductanteriorlyoverthemassetermuscletosupplythebuccinator,upperlip,andnostrilmusclesBuccalbranchescaneitherarisefromtheuppertemporofacialorthelowercervicofacialdivisione marginal mandibular branchcoursesalongtheinferiorborderoftheparotidglandtoinnervatethelowerlipandchinmusclesItsupercialtothepos teriorfacialveinandretromandibularveinstheplaneofthedeepcervicalfasciadirectlybeneaththeplatysmamusclee cervical branchsuppliestheplatysmamuscleLikethemarginalmandibularbranch,itislocatedwithintheplaneofthedeepcervicalfasciadirectunderneaththeplatysmaSmallconnectionscanexistamongthetemporal, gomatic,andbuccalbranches,andanatomicvariationsfacialnervebranchingpatternsoccurcommonlyEach terminalbranchcanbelocateddistallyandtracedretro gradeacrosstheparotidglandtothemaintrunkofthefacialnerveefacialnervecanalsobeidentiedatthestylomastoidforamenbyperformingmastoidectomyidenticationbytheusuallandmarksisnotpossiblele   10,   23]....egreatauricularnerveissensorybranchofthecervicalplexus,particularlyandandinnervatestheposteriorportionofthepinnaandthelobuleenerveparallelstheexternaljugularveinalongthelateralsurfaceofthesternocleidomastoidmuscletothetailoftheparotidgland,whereitsplitsintoanteriorandposte riorbranchesegreatauricularnerveisoeninjuredduringparotidectomy,whichcanresultlong-termsen sorylossthelobuleHarvestingofthisnervecanbeusedforfacialnervegraingcertaincaseseauriculotemporalnerveisbranchoftheman dibularnerve,thethirdinferiorsubdivisionofthe tri geminalnerve Aerexitingtheforamenovale,thenervetraversessuperiorlytoinnervatetheskinandscalpimmediatelyanteriortotheearItscourserunsparalleltothesupercialtemporalvesselsandanteriortotheexter nalauditorycanalAutonomicNerveInnervationeglossopharyngealnerveprovidesvisceralsecretoryinnervationtotheparotidglandenervecarriespreganglionicparasympatheticbersfromtheinferiorsalivatorynucleusthemedullathroughthejugularforamen(FigDistaltotheinferiorgan glion,smallbranchof Jacobsen’s nervereen terstheskullthroughtheinferiortympaniccanaliculusandintothemiddleeartoformthe tympanic plexus epreganglionicbersthencoursealongasthelesserpetrosalnerveintothemiddlecranialfossaandouttheforamenovaletosynapsethe otic ganglionPostgan glionicparasympatheticbersexittheoticganglionbe neaththemandibularnervetojointheauriculotemporalnervetheinfratemporalfossaesebersinnervatetheparotidglandforthesecretionofsalivaPostgangli onicsympatheticbersinnervatesalivaryglands,sweatglands,andcutaneousbloodvesselsthroughtheexternalcarotidplexusfromthe superior cervical ganglionAce tylcholineservesastheneurotransmitterforbothpost ganglionicsympatheticandparasympatheticberss. . . . isphysiologiccoincidenceallowsforthedevelopmentof“gustatorysweating”(alsoknownasFrey’ssyndrome) 4 1 F.ChristopherHolsingerandDanaT.Bui followingparotidectomyy   26]. . . . Patientsdevelopsweat ingandushingoftheskinoverlyingtheparotidregionduringeatingduetoaberrantautonomicreinnervationofthesweatglandsbytheregeneratingparasympatheticbersfromanyresidualparotidglandFrey’ssyndromemayoccurasmanyasofpatientspostopera tivelyeriskforFrey’ssyndromecanbeminimizedrstbycompleteandmeticuloussupercialparotidectomySecond,bydevelopingskinapsofappropriatethick ness,exposedapocrineglandsoftheskinareprotectedfromingrowthandstimulationbytheseveredbranchesoftheauriculotemporalnerveandtheirparasympatheticstimulationduringmealserearenumerousnonsurgi calandsurgicaltreatmentsforpersistentFrey’ssyndromefollowingparotidectomy(seeChapterTreatmentofFrey’sSyndrome) ArterialSupplyebloodsupplytotheparotidglandisfrombranchesofthe external carotid arterywhichcoursessuperiorlyfromthecarotidbifurcationandparalleltothemandibleundertheposteriorbellyofthedigastricmuscleear terythentravelsmedialtotheparotidglandandsplitsintotwoterminalbranchese supercial temporal arteryrunssuperiorlyfromthesuperiorportionoftheparotidglandtothescalpwithinthesuperiorpretragalregione maxillary arteryleavesthemedialportionoftheparotidandsuppliestheinfratemporalfossaandthepterygopalatinefossaDuringradicalparotidectomy,thisvesselmustbecontrolledespeciallywhenmarginalorsegmentalmandibulectomyisrequirede transverse facial arterybranchesothesupercialtemporalarteryandrunsanteriorlybetweenthezygomaandparotidducttosupplytheparotidgland,parotidduct,andthemas setermuscle Fig. 1.2: Parasympatheticsupplytothemajorsalivaryglands 5 Anatomy,Function,andEvaluation Chapter oorofthemouthsubmucosalplaneBeneaththemandible,smallmotornervebranchesoandtrav elsposteriorlyfromthelingualnervetoinnervatethemylohyoidmuscleesebersareusuallysacricedduringsurgicalremovalofthesubmandibularglandParasympatheticbersarecarriedviathelingualnervetothesubmandibularganglion,andpostsynapticbersexitalongthecourseofthesubmandibularductto nervatetheglandehypoglossalnervesuppliesmotorinner vationtoallextrinsicandintrinsicmusclesofthetongueexceptforthepalatoglossusmuscleFromthehypoglos salcanalatthebaseoftheskull,thenerveispulled feriorlyduringembryonicdevelopmentdownintotheneckbytheoccipitalbranchoftheexternalcarotidar teryFromhere,thehypoglossalnervetravelsjustdeeptotheposteriorbellyofthedigastricmuscleandcommontendonuntilitreachesthesubmandibulartriangleHeredeepthetrianglecoveredbythinlayeroffasciaItslocationisanterior,deepandmedialrelativetothesubmandibularglandTypicallythenervehascloserelationshiptotheanteriorbellyofthedigastricmuscleItthenascendsanteriortothelingualnerveanditsgenudeeptothemylohyoidmuscleExtremecareshouldbetakentopreservethisimportantnerveduringheadandnecksurgeryArterialSupplyBoththesubmandibularandsublingualglandsaresup pliedbythe submentaland sublingual arteriesbranchesofthelingualandfacialarteriese facial arterythetor tuousbranchoftheexternalcarotidartery,isthemainarterialbloodsupplyofthesubmandibularglandItrunsmedialtotheposteriorbellyofthedigastricmuscleandthenhooksovertocoursesuperiorlydeeptotheglandearteryexitsatthesuperiorborderoftheglandandtheinferioraspectofthemandibleknownasthe facial notchItthenrunssuperiorlyandadjacenttotheinferiorbranchesofthefacialnerveintotheDuringsub mandibularglandresection,thearterymustbesacricedtwice,rstattheinferiorborderofthemandibleandagainjustsuperiortotheposteriorbellyofthedigastricmusclee lingual arterybranchesinferiortoorwiththefacialarteryotheexternalcarotidarteryItrunsdeeptothedigastricmusclealongthelateralsurfaceofthemiddleconstrictorandthencoursesanteriorandmedialtothehyoglossusmuscle VenousDrainageesubmandibularglandismainlydrainedbythe an - terior facial veinwhichiscloseapproximationtothefacialarteryasitrunsinferiorlyandposteriorlyfromthetotheinferioraspectofthemandibleBecauseitjustdeeptothemarginalmandibulardivisionofthefacialnerve,ligationandsuperiorretractionoftheanterior cialveincanhelppreservethisbranchofthefacialnerveduringsubmandibularglandsurgeryItformsextensiveanastomoseswiththeinfraorbitalandsuperiorophthal veinse common facial veinisformedbytheunionoftheanteriorandposteriorfacialveinsoverthemiddleaspectoftheglandecommonfacialveinthencourseslateraltotheglandandexitsthesubmandibulartriangletojointheinternaljugularveinLymphaticDrainageeprevascularandpostvascularlymphnodesdrainingthesubmandibularglandarelocatedbetweentheglandanditsfascia,butarenotembeddedtheglandulartis sueeycloseapproximationtothefacialarteryandveinatthesuperioraspectoftheglandandemptyintothedeepcervicalandjugularchainsesenodesarefrequentlyassociatedwithcancerstheoralcavity, peciallythebuccalmucosaandtheoorofthemouthus,whenligatingthefacialarteryanditsassociatedplexusofveins,greatercaremustbetakennotonlytore sectallassociatedlymphoadiposetissue,butalsotopre servethemarginalmandibularbranchofthefacialnerve,whichrunscloseproximitytothesestructures SublingualGland esmallestofthemajorsalivaryglandsisthesublingualgland,weighingConsistingmainlyofmucous narcells,itasatstructuresubmucosalplanewithintheanterioroorofthemouth,superiortothemy lohyoidmuscleanddeeptothesublingualfoldsoppositethelingualfrenulumum. . . . Lateraltoitarethemandibleandgenioglossusmuscleereisnotruefascialcapsulesurroundingthegland,whichisinsteadcoveredbyoralmucosaonitssuperioraspectSeveralducts of Rivinusfromthesuperiorportionofthesublingualglandeithersecretedirectlyintotheoorofmouth,oremptyinto Bartholin’s ductthatthencontinuesintoWharton’sduct 8 1 F.ChristopherHolsingerandDanaT.Bui Boththesympatheticandparasympatheticnervoussystemsinnervatethesublingualglandepresynapticparasympathetic(secretomotor)bersofthe facial nerve arecarriedbythechordatympaninervetosynapsethesubmandibularganglionPostganglionicbersthenexitthe submandibular ganglionandjointhelingualnervetosupplythesublingualglandSympatheticnervesinner vatingtheglandtravelfromthe cervical ganglionwiththefacialarteryy....Bloodissuppliedtothesublingualglandbythe sub - mental and sublingual arteriesbranchesofthelingualandfacialarteries,respectivelyevenousdrainageparallelsthecorrespondingarterialsupplyesublingualglandismainlydrainedbythesubmandibularlymphnodes Ranulasarecystsormucocelesofthesublingualgland,andtheycanexisteithersimplywithinthesublingualspaceorplungingposteriorlytothemylohyoidmuscleintothenecksimpleranulawillmostcommonlypres entasbluish,nontendermasstheoorofthemouthandmayeitherberetentioncystoranextravasationpseudocystplungingranulawillpresentasso,painlesscervicalmassandisalwaysanextravasationpseudocyst(seeChapterManagementofMucoceleandRanula) MinorSalivaryGlands Abouttominorsalivaryglands,rangingfromtolinetheoralcavityandorophar ynxegreatestnumberoftheseglandsarethelips,tongue,buccalmucosa,andpalate,althoughtheycanalsobefoundalongthetonsils,supraglottis,andparana salsinusesEachglandhassingleductwhichsecretes,directlyintotheoralcavity,salivawhichcanbeeitherse rous,mucous,ormixedPostganglionicparasympatheticinnervationarisesmainlyfromthe lingual nerveepalatinenerves,how ever,exitthesphenopalatinegangliontoinnervatethesuperiorpalatalglandseoralcavityregionitselfdeter minesthebloodsupplyandvenousandlymphaticdrain ageoftheglandsAnyofthesesitescanalsobethesourceofglandulartumors Histology Allglandsgeneralarederivedfromepithelialcellsandconsistof parenchyma(thesecretoryunitandassociatedducts)and stroma(thesurroundingconnectivetissuethatpenetratesanddividestheglandintolobules)SecretoryproductsaresynthesizedintracellularlyandsubsequentlyreleasedfromsecretorygranulesbyvariousmechanismsGlandsareusuallyclassiedintotwomaingroups Endo - crine glandscontainnoducts,andthesecretoryproductsarereleaseddirectlyintothebloodstreamorlymphaticsystemIncontrast, exocrine glandssecretetheirproductsthroughductsystemthatconnectsthemtotheadjacentexternalorinternalepithelialsurfacesSalivaryglandsareclassiedasexocrineglandsthatsecretesalivathroughductsfromask-like,blind-endedsecretorystructurecalled the salivary acinus.eacinusitselfcanbedividedintothreemaintypes Serous acinisalivaryglandsareroughlysphericalandreleaseviaexocytosiswateryproteinsecretionthatisminimallyglycosylatedornonglycosylatedfromsecre tory(orzymogen)granuleseacinarcellscomprisingtheacinusarepyramidal,withbasallylocatednucleisur roundedbydensecytoplasmandsecretorygranulesthataremostabundanttheapex Mucinous acinistorevis cous,slimyglycoprotein mucinwithinsecretorygran ulesthatbecomehydratedwhenreleasedtoform mucus Mucinousacinarcellsarecommonlysimplecolumnarcellswithattened,basallysituatednucleiandwater-solu blegranulesthatmaketheintracellularcytoplasmappearclear Mixedor seromucous acinicontaincomponentsofbothtypes,butonetypeofsecretoryunitmaydominateMixedsecretoryunitsarecommonlyobservedasserous demilunes(orhalf-moons)cappingmucinousBetweentheepithelialcellsandbasallaminaoftheacinus,at myoepithelial cells(orbasketcells)formlat ticeworkandpossesscytoplasmiclamentsontheirbasaltoaidcontraction,andthusforcedsecretion,oftheacinusMyoepithelialcellsarealsoobservedaroundintercalatedducts,butheretheyaremorespindleshapedd....Electrolytemodicationandtransportationofsalivaarecarriedoutbythedierentsegmentsofthesalivarygland’sductsystem(Figerstsecretethroughsmallcanaliculiintotheintercalatedducts,whichturnemptyintostriatedductswithintheglan dularlobuleeintercalatedductiscomprisedofan regularmyoepithelialcelllayerlinedwithsquamousorlowcuboidalepitheliumBicarbonateissecretedintowhilechlorideisabsorbedfromtheacinarproductwithintheintercalatedductsegmentStriatedductshavedistin guishingbasalstriationsduetomembraneinvaginationandmitochondriaandarelinedbysimplecolumnar 9 Anatomy,Function,andEvaluation Chapter epitheliumeseductsareinvolvedwiththereabsorp tionofsodiumfromtheprimarysecretionandthecon comitantsecretionofpotassiumintotheproducteabundantpresenceofmitochondriaisnecessaryfortheducts’transportofbothwaterandelectrolytese nus,intercalatedduct,andstriatedductarecollectivelyknownassinglesecretoryunitcalled salivon n ....enextsegmentoftheductsystemismarkedbytheappearanceoftheinterlobularexcretoryductswithintheconnectivetissueoftheglandularseptaeeepithelialliningiscomprisedofsparsegobletcellsinterspersedamongthepseudostratiedcolumnarcellsAsthediam eteroftheductincreases,thecompositionoftheepithe lialliningtransitionstostratiedcolumnar,andthentononkeratinizedstratiedsquamouscells,withintheoralcavityy....earterialbloodowreceivedbythesalivaryglandsishighrelativetotheirweightandisoppositetheowofsalivawithintheductsystemeandductulesaresuppliedbyseparateparallelcapillarybedsehighpermeabilityofthesevesselspermitsrapidtransferofmoleculesacrosstheirbasementmembranesehighvolumeofsalivaproducedbythesalivaryglandsrelativetotheirweightispartlyduetothehighbloodowratethroughtheglandulartissueeserousthatmakeupthe parotid glandareroughlyspherical,andtheyarecomprisedofpyramidalepithelialcellssurroundedbydistinctbasementmem braneMerocrinesecretionbytheepithelialcellsreleasessecretorymixturecontainingamylase,lysozyme,anIgAsecretorypiece,andlactoferrinintothecentrallu menoftheacinusemainexcretoryductisalsoknownas Stensen’s ductandemptiesintotheoralcavityoppositetheseconduppermolartoothe submandibular glandisclassiedasmixedglandthatispredominantlyserouswithtubularema jorityofacinarcellsareserouswithverygranulareosino philiccytoplasmOnlyapproximatelyofthearemucinous,withlarge,triangularacinarcellscontainingcentralnucleiandclearcytoplasmicmucinvacuolesrang ingemucinouscellsarecappedbydemilunes,whicharecrescent-shapedformationsofserouscellseintercalatedductsofthesubmandibularglandarelongerthanthoseoftheparotidgland,whilestriatedductsareshorterbycomparison Wharton’s ductservesasthemainexcretoryductandemptiesintotheoorofthemouthLikethesubmandibulargland,the sublingual gland hasmixedwithobservableserousdemiluneswithintheglandulartissueUnlikethesubmandibulargland,however,thesublingualglandispredominantly Fig. 1.4: Functionalhistologyofthesalivon 10 1 F.ChristopherHolsingerandDanaT.Bui trationswithinthecell,releasedfromeitherintracellular Ca storesorfromtheplasmaissecondmessengersignicantlyeectssalivaryvolumesecretionGlandu larsecretionissustainedby acetylcholinesteraseswhichinhibitthebreakdownofAChemuscarinicantago nist atropinehowever,decreasessalivationbycompetingwithAChforthesalivaryreceptorsiteesympatheticsupplytothesalivaryglandismainlyfromthethoracicspinalnervesofthesuperiorcervicalganglionLikeparasympatheticinnervation,myoepithe lialcellcontractionalsoresultsChangesbloodow,however,arebiphasic:vasoconstrictiondueto-adren ergicreceptoractivationisfollowedbyvasodilationduetobuildupofvasodilatormetabolitesBindingoftheneurotransmitter norepinephrineto-adrenergicrecep torresultsformationof3',5'-cyclicadenosinemono phosphatewhichthenleadstophosphorylationofvariousproteinsandactivationofdierentenzymesIncreasesresultincreasedsalivaryenzymeandmucuscontentWithinsaliva, concentrationsincreasewhileNa + concentrationsdecreasethepresenceofantidiuretichormone(ADH)oraldosteroneUnlikeotherdigestiveglands,however,thesetwohormonesnotaectsali varyglandsecretionrateAboutofsalivaissecretedbynormaladulteachdayDuringunstimulatedsalivation,ofsalivaiscon tributedbythesubmandibularglands,bytheparotid,andbythesublingualglandserelativeamountssuppliedbytheparotidandsubmandibularglands,how ever,areswitchedduringstimulation,wheretwothirdsofsecretionisthenfromtheparotidglandtotalow,isduetotheminorsalivaryglandsregardlessofstimulationepresenceoffoodthemouth,theactofchewing,andnauseaallstimulatesalivation,whilesleep,fatigue,dehydration,andfearinhibititSalivarysecretionratesarenotdependentonage,andowratesremainconstantdespitethedegenerationofacinarcellsduringtheagingprocessMedicationeectsorsystemicdis easearemorelikelytoberesponsibleforhypofunctionofsalivaryglandselderlypatients EvaluationoftheSalivaryGlands Symptomsindicativeofsalivaryglanddisordersare itednumberandgenerallynonspecicPatientsusu allycomplainofswelling,pain,xerostomia,foultaste,andsometimes sialorrheaorexcessivesalivationDespite theprevalenceofmoderntechnologytheidenticationofsalivaryglanddisorders,detailedhistoryandthor oughphysicalexaminationstillplaysignicantrolestheclinicaldiagnosisofthepatient,andgreatcareshouldbetakenduringtheseinitialstepsofevaluation HistoryWhentakingpatient’shistory,thepracticedskillsofattentivelisteningandpatiencearerequiredforsubse quentdiagnosisandpropertreatmentmostttingtothepatient’sexpectationsandneedsemedicalproleofthepatientcanprovidehelpfulcluestothecurrentcondi tionofthesalivaryglands,fordysfunctionoftheseglandsisoenassociatedwithcertainsystemicdisorderssuchasdiabetesmellitus,arteriosclerosis,hormonalimbalances,andneurologicdisordersEitherxerostomiaorsialorrhea,forinstance,maybeduetofactorsaectingthemedul larysalivarycenter,autonomicoutowpathway,salivaryglandfunctionitself,oruidandelectrolytebalanceefactorsofagegroupandgenderarealsoimpor tant,forseveraldiseasesareoenrelatedtoageorgendereautoimmunedisorderknownas Sjögren’s syndromeforexample,iscommonmenopausalwomen,while mumpsparotidswellingduetoparamyxoviralinfec tion,usuallyoccurschildrenbetweentheagesofandyearsDrughistoryofthepatientshouldalsobeconsidered,forsalivaryfunctionisoenaectedbydrugusageXe rostomiaisoenduetotheuseofdiureticsandotheran tihypertensivedrugsugs   18]....A   carefuldietaryandnutritionhistoryshouldbeob tainedPatientswhoaredehydratedchronicallyfrombu limiaoranorexiaorduringchemotherapyareatriskforparotitisSwellingandpainduringmealsfollowedbyreductionsymptomsaermealsmayindicatepartialductalstenosisXerostomiaisdebilitatingconsequenceofradiationtherapytotheheadandneckandhistoryofpriorradia tionshouldbesoughtPhysicalExaminationesuperciallocationofthesalivaryglandsallowsthor oughinspectionandpalpationforcompletephysicalexaminationInitialinspectioninvolvesthecareful aminationoftheheadandneckregions,bothintraorally 13 Anatomy,Function,andEvaluation Chapter andextraorally,andshouldbecarriedoutsystematicwaysoastonotmissanycrucialsignsDuringtheinitial extraoral inspectionthepatientshouldstandthreetofourfeetawayanddirectlyfacingfrontoftheexaminereexaminershouldinspectsymmetry,color,possiblepulsationanddischargingof nusesonbothofthepatientEnlargementofmajororminorsalivaryglands,mostcommonlytheparotidorsubmandibular,mayoccurononeorboth Parotitis typicallypresentsaspreauricularswelling,butmaynotbevisibledeeptheparotidtailorwithinthesubstanceofthegland Submandibular swellingpresentsjustmedialandinferiortotheangleofthemandibleSalivaryglandswellingcangenerallybedierentiatedfromthoseoflym phaticoriginasbeingsingle,larger,andsmoother,butthetwotypesareoeneasilyconfusedSignicantneurologicdecitsshouldbeexaminedaswellFacialnerveparalysisconjunctionwithparotidmass,forexample,shouldremindusof malignantparotidneoplasm,althoughitdoesoccurrarelywithbenignneoplasmsaswellInadditiontosignsofpossibleasymmetry,discolor ation,orpulsation, intraoral inspectionalsoincludesas sessmentoftheductoricesandpossibleobstructionseproperlightingwithheadlightshouldalwaysbeusedwheninspectingwithintheoralcavityandpharynxeopeningsofStensen’sandWharton’sductscanbe spectedintraorallyoppositetheseconduppermolarandattherootofthetongue,respectivelyDryingothemu cosaaroundtheductswithanairblowerandthenpress ingonthecorrespondingglandswillallowtheexaminertoassesstheoworlackofowofsalivaSialolithiasiscansometimesbefoundbycarefulintraoralpalpationDentalhygieneandthepresenceofperiodontaldiseaseshouldalsobenotedsincedecientoralmaintenanceismajorpredisposingfactortovariousinfectiousdiseasesSize,consistency,andotherqualitiesofthesalivaryglandsandassociatedmassescanbeevaluatedthroughextraoralandintraoralpalpationBimanualassessmentshouldbeperformedwheneverpossiblewiththepalmaraspectofthengertipsDuring extraoral palpationoftheandneck,thepatient’sheadisinclinedforwardtomaximallyexposetheparotidandsubmandibularglandregionseexaminermaystandfrontoforbehindthepatientItshouldbenotedthatobservablesalivaryorlymphaticglandswell ingsnotrisewithswallowing,whileswellingsassoci atedwiththethyroidglandandlarynxelevateFinally,bimanualpalpation(extraoralwithonehand,introralwiththeother)mustbeperformedtoexam - inetheparotidandsubmandibularglandsOneortwoglovedngersshouldbeinsertedwithintheoralcavitytopalpatetheglandsandmainexcretoryductsinternally,whileusingtheotherhandtoexternallysupporttheheadandneckByrollingthehandsovertheglandsbothinter nallyandexternally,subtlemasslesionscanbeidentiedInthesubmandibulargland,lymphnodesextrinsictotheglandcanoenbedistinguishedfrompathologywithintheglanditselfusingthistechniqueeneckshouldthenalsobecarefullyexaminedforlymphadenopathyFinally,carefulsurveyofminorsalivaryglandtis sueshouldbeperformed,especiallytheanteriorlabial,buccal,andposteriorpalatalmucosaIncreasedsalivationfromtheductoricesduetopressureexternallyappliedtotheglandsmayindicateinammationn   18]. . . . Finally,rareclinicalentities,suchashemangiomasandothervas cularanomalies,maybeidentiedbyauscultation RadiologicandEndoscopicExaminationoftheSalivaryGlands Althoughthoroughhistoryandcompletephysical aminationarecrucialstepsthediagnosisandeven tualtreatmentofanysalivaryglanddisorder,patientsoccasionallyprovidelittlemorethanvaguecomplaintsofpainand/orswellingForpatientswiththeseunclearsymptomsandnophysicalsigns,radiographicdiagnosticstudies,suchassialography,plain-lmradiography,com putedtomography,andmagneticresonanceimaging,canplayimportantroleclarifyingtheetiologyofsuchnonspecicsymptomsForpatientswithknowndisease,imagingcanassisttreatmentselectionandplanningisnalsectionwillprovidebriefintroductiontothesevarioustechniques,whichwillthenbecoveredgreaterdetailsubsequentchaptersSialographyreliesontheinjectionofcontrastmediumintoglandularductssothatthepathwayofsalivaryowcanbevisualizedbyplain-lmradiographsCorrect posureandpositioningisachievedbytakingpreliminaryplainradiographspriortotheinjectionofradiopaquemediumum. . . . emostcommonindicationforsialogra phyisthepresenceofsalivarycalculus,whichis positofmostlycalciumsaltsthatcanblockowofsa livaandcausepain,swelling,andinammationorleadtoinfectionPatientswithcalculiusuallycomplainofrecurrentandacuteonsetofpainandswellingduringeatingOen,sialographicexaminationisunnecessarythepreliminaryradiographsdetectthecalculusbefore - 14 1 F.ChristopherHolsingerandDanaT.Bui handOtherindicationsforsialographyincludegradualorchronicglandularenlargement(whichcanbeduetosarcoidosis,infection,sialosis,Sjögren’ssyndrome,be nignlymphoepitheliallesion,orneoplasm),clinicallypalpablemassoneoftheglandularregions(possibletumor,cyst,orfocalinammation),recurrentsialadeni tis,ordrynessofthemouthAlthoughconventionalsialographycanbeclinicallyusefulthediagnosisandthedeterminationoftreat mentforvarioussalivarydisorders,itseectivenessre mainsarguablewhileitsrateofusageishighlyvariablele   30]. . . . ismethodshouldnotbeperformedwhenthepatienthasanacutesalivaryglandinfection,hasknownsensitivitytoiodine-containingcompounds,orisan ticipatingthyroidfunctiontestsus,othermethodsofradiographicdiagnosisarecurrentlypreferredandhavelargelyreplacedsialographicexaminationComputedtomographyisnowmorewidelyusedtoassesstheparotidandsubmandibularglandse vantageofimagingisthetwo-dimensionalviewofthesalivaryglands,whichcanelucidaterelationshipstoadja centvitalstructuresaswellastoassessthedrainingcervi callymphaticseparotidglandhaslowattenuationduetoitshighfatcontentandisthereforeeasilydiscerniblebyscanningesubmandibularglandhaslowerfatcontentandhigherdensitycomparedtotheparotidglandandthushasmuchhigherattenuation,althoughextrin andintrinsicmassdierentiationiseasiertoevaluateAlthoughstonescanbeidentied,salivaryglandinam mationisnotgenerallyanindicationforWhileisoenutilizedasprimaryscreeningtoolforthedetec tionofparotidandsubmandibularglandabnormalities,dicultcases,higher-sensitivityapproachusingbothandsialography(CT-sialography)canbeusedd. . . . Dierencesbetweenintrinsicandextrinsicparotidglandmasses,however,areoendiculttoassessespeciallywhenpresenttheparapharyngealspaceace....Magneticresonanceimagingismoreoenusedforassessmentofparapharyngealspaceabnormalitiesprovidesbettercontrastresolution,exposesthepa tienttolessharmfulradiation,andyieldsdetailedimagesonseveraldierentplaneswithoutpatientrepositioningistechniquethereforeispreferredtheevaluationofparapharyngealspacemasses,especiallydiscriminatingbetweendeeplobeparotidtumorsandotherpathology,suchasschwannomaand/orglomusvagalehowever,isinferiortoscanningforthedetectionofcalcicationsandearlyboneerosionChronicinammationofthesali varyglandsandcalculiarenotindicationsfor Sialendoscopyisminimallyinvasivetechniquethatinspectsthesalivaryglandsusingnarrow-diameter,rigidberopticendoscopeses. . . . Endoscopicvisualizationofductalandglandularpathologyprovidesanexcellental ternativetotheindirectdiagnostictechniquesdescribedaboveAssuch,sialendoscopyhasopenedupnewfron tierforbothevaluationandtreatmentofsalivaryglanddiseasee. . . . Lacrimalprobesareusedtogentlydilatetheductaloriceandthentheendoscopeisintroduced directvisualizationDuringlavageoftheglandularductofinterest,directinspectionoftheductandhilumoftheglandisperformedus,onesetting,atthetimeofdiagnosis,treatmentandtherapyforbenignlesionscanbeperformed(seeChapterSialendoscopy)roughCO -laserpapillotomy,sialolithectomycanbeeasilyperformedd. . . . Pharmacotherapyandlaser-ablationcanalsobeperformedSialendoscopyhasalsobeenshowntohavesignicantlylowcomplicationrateandisgener allywell-toleratedd. . . . isrelativelynewtechniquehasshownmuchpromisethediagnosisandtreatmentofchronicobstructivesialadenitis(COS),sialolithiasis,andotherobstructivediseasesofthesalivaryglands TakeHomeMessages  SalivaryglanddevelopmentistheresultofbranchingmorphogenesisMolecularbiologyisbeginningtounravelsignalingpathways plicatedbothcraniofacialdevelopmentandsalivaryglandhistogenesis,includingthesonichedgehog(Shh)andthebroblastgrowthfactorfamily  Humansalivaisnotonlyimportantforlubrica tiontheoralcavity,butplayscrucialroledigestiveandprotectiveprocesses  Bothvisualinspectionwithoptimallightingandbimanualpalpationiscrucialtheprecisephys icalexaminationofthemajorandminorsalivaryglands  Sialendoscopyisnovelmodalityfordiagnosticevaluationaswellastherapeuticinterventionfordisordersofthesalivaryglands 15 Anatomy,Function,andEvaluation Chapter References AreyDevelopmentalanatomy;textbookandlaboratorymanualofembryologyRevised7thedSaunders,IncPhiladelphia BerneldBanerjeeCohnDependenceofsalivaryepithelialmorphologyandbranchingmorphogen esisuponmucopolysaccharide-protein(proteoglycan)attheepithelialsurfaceCellBiol BhattacharyyaVarvaresAnomalousrelation shipofthefacialnerveandtheretromandibularvein:casereportOralMaxillofacSurg CarrauJohnsonJT,MyersManagementoftumorsoftheparapharyngealspaceOncology(WillistonPark)discussion DavisRA,AnsonBJ,BudingeralSurgicalanatomyofthefacialnerveandparotidglandbaseduponstudyofcervicofacialhalvesSurgGynecolObstet Frommerehumanaccessoryparotidgland:itsincidence,nature,andsignicanceOralSurgOralMedOralPathol Garatea-CrelgoJ,Gay-EscodaBermejoB,alMorphologicalstudyoftheparotidlymphnodesCranio maxillofacSurg Gibsoneprenatalhumansubmandibulargland:histological,histochemicalandultrastructuralstudyAnatAnz GraamansvonAkkerHistoryandphysi calexaminationIn:Graamans(ed)DiagnosisofSali varyGlandDisordersKluwerAcademicPublishers,Dor drecht,Germany,pp GrantAnAtlasofAnatomy,SixthednWilliamsWilkins,Baltimore HollinsheadAnatomyforSurgeons:VolumeeHeadandNeck,irdedLippincottCompany, Philadelphia JaskollT,MelnickSubmandibularglandmor phogenesis:stage-specicexpressionofTGF-alpha/EGF,IGF,TGF-beta,TNF,andIL-6signaltransductionnor malembryonicandthephenotypiceectsofTGF-beta2,TGF-beta3,andEGF-rnullmutationsAnatRec JaskollT,LeoT,WitcherD,alSonichedgehogsignalingplaysanessentialroleduringembryonicsalivaryglandepithelialbranchingmorphogenesisDevDyn Johnsesalivaryglands:anatomyembryol ogyOtolaryngolClinNorthAm Johnson(ed)SecretionElsevier,Amsterdam JunqueriaCarneiroBasicHistology:TextAt lasTenthednMcGraw-Hill,NewYork KontisTC,JohnsAnatomyandPhysiologyoftheSalivaryGlandsIn:Bailey(ed)HeadandNeckSurgeryOtolaryngologyLippincottWilliamsWilkins, Philadelphia MasonD,ChisholmSalivaryGlandsHealthandDiseaseSaunders,London MyersConleyGustatorysweatingaerradicalneckdissectionArchOtolaryngol NahlieliO,BaruchinSialoendoscopy:threeyears’experienceasdiagnosticandtreatmentmodalityOralMaxillofacSurgdiscussion NahlieliO,BaruchinLong-termexperiencewithendoscopicdiagnosisandtreatmentofsalivaryglandinammatorydiseasesLaryngoscope OrabiRiadO’ReganStylomandibu lartenotomythetranscervicalremovaloflargebenignparapharyngealtumoursBrOralMaxillofacSurg PogrelSchmidtB,AmmarerelationshipofthebuccalbranchofthefacialnervetotheparotidductOralMaxillofacSurg QuinnJrSymposium:managementoftumorsoftheparotidglandDiagnosisofparotidglandswellingLaryngoscope RabinovWeberRadiologyoftheSalivaryGlandsHallMedicalPublishers,Boston RoarkDT,SessionsRB,AlfordBRFrey’ssyndrome-technicalremedyAnnOtolRhinolLaryngol SomBillerecombinedcomputerizedtomography-sialogramtechniquetodierentiatedeeplobeparotidtumorsfromextraparotidpharyngomaxillaryspacetumorsAnnOtolRhinolLaryngol UeharaLocalizationofFGF-6andFGFR-4dur ingprenatalandearlypostnataldevelopmentofthemousesublingualglandOralSci WoodburneRT,BurkelEssentialsofHumanAnatomy,EighthednOxfordUniversityPress,NewYork, Oxford YuneSialographyanddacrocystographyIn:MillerR,Skucas(eds)RadiographiccontrastagentsUni versityParkPress,Baltimore,pp ZieglerHedemarkBrevikB,alEndos copyasminimalinvasiveroutinetreatmentforsialolithia sisActaOdontolScand 16 1 F.ChristopherHolsingerandDanaT.Bui