Anatomy ‣ Salivary Gland Cancer ‣ THANC Guide

Video Summary

• There are 3 major salivary glands on each side of the face:
  • The parotid gland, located in front of the ear,
  • The submandibular gland, located below the jaw bone, and
  • The sublingual gland, located under the tongue.
• There are many minor salivary glands located throughout the mouth, tongue, and throat, which are much smaller than the major glands.
• There are many important nerves that travel near the salivary glands.

In order to begin to understand salivary gland cancer, it is important to gain some background knowledge on the anatomy of the salivary glands. In the head and neck, there are two main types of salivary glands: major salivary glands and minor salivary glands. The major salivary glands consist of three different glands: parotid, submandibular, and sublingual. The glands in the face and neck are symmetrical, meaning that there is one of each on either side of the face and mouth.  

There are many different nerves that travel around and through the salivary glands. The location of these nerves is important, as they can become involved by salivary gland tumors. If surgery becomes necessary to treat salivary gland cancer, these nerves must be identified and monitored very carefully in the hopes of preserving their function.  

Major Salivary Glands 

Illustration of the parotid gland sublingual gland and submandibular gland © Jill Gregory

The major salivary glands include the parotid glands, the submandibular glands, and the sublingual glands. They are called “major” because they are larger than the minor salivary glands. Each major salivary gland is surrounded by an envelope or fascial layer, and each one has its own tube (or duct) that connects it to the mouth and transports the saliva produced by the gland.

Parotid Salivary Glands 

The parotid glands are the largest salivary glands, sitting in front of each ear and extending from below the cheekbones to the level of the angle of the lower jaw and back below the ear lobe. The glands sit on top of the masseter muscle, which is the main muscle used for chewing. The parotid glands taper down at the bottom into a “tail,” from which the saliva-carrying tubes join together to become a single duct (called the “Stenson’s duct”) that leaves the gland and travels to the mouth. The parotid glands produce the most saliva out of any of the other glands. The nerve that controls the movement of the face, called the facial nerve, travels through the middle of the parotid glands. It forms multiple branches within the gland that control the 17 muscles for facial expression on each side of the face and are therefore very important. Surgeons will work to locate and preserve these nerve branches when operating on the parotid gland.

The parotid glands are the most common sites of salivary gland tumors, as 80% of salivary gland tumors arise in the parotid gland. However, most of these parotid tumors are benign and not cancerous. Just like the other major salivary glands, the parotid glands are enclosed by envelopes, which happen to also contain lymph nodes. This means that a lump in a parotid gland could actually be a lymph node that is enlarged due to cancer from another part of the body, or due to infection and inflammation (non-cancerous). The most common cause for an enlarged and cancerous parotid lymph node is due to a skin cancer located on the side of the face or head.

Submandibular Salivary Glands 

The submandibular glands lie in what is called the submandibular triangle, the area of the neck below the jawbone. The main saliva-carrying tube from the submandibular gland is called “Wharton’s duct,” and it opens into the mouth right under the tongue. One of the branches of the facial nerve runs just over the top of the submandibular gland and is called the marginal mandibular nerve.  This nerve controls the lower lip and allows it to move downwards during normal facial expression. 

Sublingual Salivary Glands 

The sublingual glands sit on the floor of the mouth under the tongue, with one gland on either side of the mouth. The lingual nerves, which provide sensation to the sides of the tongue, run in very close proximity to these glands. The saliva-carrying tubes from these glands are called the “ducts of Rivinus,” and they open directly into the mouth.

Minor Salivary Glands 

The minor salivary glands are much smaller than the major salivary glands. They are not surrounded by envelopes and do not have their own saliva-carrying tubes. There are thousands of minor salivary glands throughout the mouth, tongue and throat, but they are mainly located in a few places: the junction of the hard and soft palate on the roof of the mouth, lips, and along the inside of the cheeks.

Anatomy, Head and Neck, Parotid Gland – StatPearls

Hannah M. Chason; Brian W. Downs.

Author Information and Affiliations

Last Update: October 24, 2022.

Introduction

The parotid gland is the largest of the three paired major salivary glands, including the submandibular and sublingual glands. It is located in the retromandibular fossa, space mainly occupied by this gland. It is bordered superiorly by the zygomatic arch, anteriorly by the masseter muscle, and posteriorly by the sternocleidomastoid muscle. However, the superficial lobe extends anteriorly, covering the mandibular ramus and the posterior area of the masseter muscle.[1]

The parotid gland and the other salivary glands play an essential function in the oral cavity because they secret saliva, facilitating chewing, swallowing, speaking, and digesting.[2]

The facial nerve courses through the body of the parotid gland, creating a unique relationship between them, which requires focused attention when performing parotidectomies or other surgery in the region. [3]

Structure and Function

The parotid glands can be palpated anterior and inferior to the lower half of the ear on the lateral surface of the cheek. They extend inferiorly to the lower border of the mandible and superiorly to the zygomatic arch. Each parotid gland comprises a superficial lobe and a deep lobe divided by the facial nerve and the posterior facial vein. Between the lobes of the gland, there is also fatty tissue that facilitates mandibular movements. The superficial lobe lies lateral to the facial nerve and overlies the lateral surface of the masseter muscle. The deep lobe lies medial to the facial nerve and is situated between the mastoid process of the temporal bone and the mandibular ramus. A fascial capsule called the parotid sheath surrounds the parotid glands.[1]

The parotid main excretory duct (Stensen’s duct) projects from the anterior portion of the superficial lobe and runs over the masseter muscle until it reaches its anterior border, from where it turns medially to penetrate the buccinator muscle [1]. It opens into the buccal cavity at the level of the buccal mucosa of the maxillary second molar.[1]

The salivary glands share the same histological structure – a secretory portion called acini and a web of arborized ducts that open into the buccal cavity realizing saliva.[2] The parotid is a serous gland composed mainly of serous acinar cells, but it may contain accessory glandular tissue formed by mucinous acinar cells. Therefore, saliva excreted by the parotid is serous and watery. Each serous acinus is surrounded by myoepithelial cells that contract to help expel secretions from the acini. Furthermore, an extracellular matrix, stromal cells, immune cells, myofibroblasts, and nerves are found in the periphery of the acini.[4]

Saliva is first produced in the acinar lumen and then altered into a mixture of electrolytes and macromolecules as it is actively transported through the ducts. The saliva is hypotonic when it reaches the mouth, but salivary flow rates can influence the electrolyte composition. In addition to electrolytes, saliva also contains mucin and digestive enzymes. The most important enzyme is amylase, which initiates the digestion of carbohydrates.[2]

Embryology

The parotid gland starts developing in the 6th week of gestation [2] via a process of proliferation, budding length, and branching. The excretory ducts and acini derive from the ectoderm, whereas the gland’s capsule and connective tissue come from the mesenchyme. The intimate relationship with the facial nerve is established from the beginning.[5]

Blood Supply and Lymphatics

Blood Supply

The external carotid artery provides blood supply to the parotid. It bifurcates into two terminal branches, the superficial temporal artery, and the maxillary artery. The superficial temporal artery gives off the transverse facial artery, which runs anteriorly between the zygoma and parotid duct and supplies the parotid duct, parotid gland, and masseter muscle. The maxillary artery supplies the infratemporal fossa and the pterygopalatine fossa after exiting the medial portion of the parotid. [5] Finally, the retromandibular vein – which forms from the confluence of the superficial temporal and maxillary veins – provides venous outflow for the parotid. It courses deep to the facial nerve, and it may exhibit variable anatomy before joining the external jugular vein.[5]

Lymphatics

The parotid gland is in intimate relation with the lymph nodes. It is the only salivary gland with two nodal layers, which drain into the superficial and deep cervical lymph system. Most nodes are located within the superficial lobe between the gland and the parotid capsule.[2] It is worth noting that skin cancers of the face or scalp can enlarge the lymph nodes in the parotid gland, indicating the regional spread of carcinoma. Lymph nodes located in the parotid substance drain the gland, middle ear, nasopharynx, palate, and external meatus; the superficial preauricular lymph nodes drain the anterior pinna, temporal scalp, eyelids, and lacrimal glands.[5]

Nerves

Sympathetic and parasympathetic fibers innervate the parotid gland. Sympathetic innervation causes vasoconstriction, and parasympathetic innervation, from the glossopharyngeal nerve (CN IX), produces the secretion of saliva.[5] The parasympathetic fibers originate in the inferior salivatory nucleus in the medulla and travel through the jugular foramen to the inferior ganglion. A small branch of the glossopharyngeal nerve, called the tympanic or Jacobsen’s nerve, forms the tympanic plexus within the middle ear. These preganglionic fibers become the lesser petrosal nerve and course through the middle cranial fossa before exiting through the foramen ovale. They synapse in the otic ganglion, and the postganglionic parasympathetic fibers join the auriculotemporal nerve to innervate the parotid gland to secrete saliva.

The neurotransmitters acetylcholine (ACh) and norepinephrine (NE) act within the parotid. ACh binds muscarinic receptors to stimulate acinar activity and ductal transport. It also uses second messenger activity, producing inositol triphosphate leading to increased calcium concentration within the cells. As a result, salivary secretion increases. Norepinephrine transmits sympathetic nervous impulses via postganglionic sympathetic fibers to the salivary glands – sympathetic outflow thickens saliva. NE binds beta-adrenergic receptors activating the adenylate cyclase second messenger system, producing cAMP, phosphorylating proteins, and activating enzymes.

The facial nerve courses through the parotid gland, providing motor supply to the muscles of facial expression but does not provide innervation to the gland.

The parotid gland is closely related to two muscles: sternocleidomastoid and masseter. The accessory nerve provides innervation to the sternocleidomastoid muscle,[6] which forms the posterior border of the retromandibular fossa. The superficial lobe of the parotid gland partly covers the mandibular ramus and the posterior part of the masseter muscle. The masseter muscle receives innervation by the masseteric nerve, a branch of the mandibular nerve.[7]

Surgical Considerations

The parotid gland is the location of 80% of salivary tumors. [5] The most common primary parotid tumor is pleomorphic adenoma. The management of neoplasias of the parotid typically includes surgical resection. Because the facial nerve courses through the glandular substance of the parotid gland, identifying this nerve is crucial when performing surgical procedures in the gland to prevent injuries. Some bony and soft tissue landmarks commonly used to identify the facial nerve trunk include the cartilaginous tragal pointer, the tympanomastoid suture, the posterior belly of the digastric muscle, the styloid process, and the retromandibular vein.[3]

If an obstructing stone (sialolithiasis) causes refractory inflammation despite medical treatment, a procedure called sialoendoscopy can be performed for relief. It uses an endoscope to visualize the stone to aiding the management.

Clinical Significance

Sialadenitis

• Sialadenitis is the inflammation of the salivary gland caused by obstruction and infection by bacteria, viruses, or stones.

• Signs and symptoms include pain, swelling of the gland, and fever.

• The most common microorganisms involved in the condition are staphylococcal bacteria and the mumps virus [8]

• Treatment includes antibiotics for bacterial infections, oral hydration, warm compresses, and drugs that induce salivary secretion. For cases of refractory infection, surgical management may be indicated (i.e., abscess drainage) [9]

Sialolithiasis

• Sialolithiasis is a benign condition caused when a stone or calculus is lodged in a salivary duct. It is the most common cause of obstructive salivary gland disease and is responsible for half of all major salivary gland disorders [10]

• Signs and symptoms include pain and swelling in the affected duct, particularly during and after eating [11]

• Ultrasound imaging is the first step in the diagnosis. CT scan, MRI, and MR sialography can be used in patients with a high suspicion for ductal obstruction that had a negative or inconclusive ultrasound study [10]

• The goal of treatment is to increase saliva flow through the duct with oral hydration and drugs that induce salivary secretion.  Surgical removal of the calculus is required for chronic sialolithiasis that has failed conservative treatment [12]

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Figure

Lymph notes of the head and Neck, Posterior auricular glands, occipital glands, Superficial cervical glands, Superior deep cervical glands, Inferior deep cervical glands, Submental glands, Submaxillary glands, Supramandibular glands, Buccinator glands, (more…)

Figure

The Mouth, Right parotid gland; Posterior and deep aspects, Parotid duct, Styloid process, Exterior carotid artery, Facial vein, Superficial temporal artery. Contributed by Gray’s Anatomy Plates

Figure

The Mouth, Right parotid gland; Deep and anterior aspects. Contributed by Gray’s Anatomy Plates

Figure

The Surface Markings of Special regions of the Head, Outline of side of face; showing chief surface markings, Mental Nerve, Exterior Maxillary Artery, Infra orbital nerve, Parotid duct, Parotid gland. Contributed by Gray’s Anatomy Plates

Figure

Parotid mass. Image courtesy S Bhimji MD

References

1.

Bialek EJ, Jakubowski W, Zajkowski P, Szopinski KT, Osmolski A. US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls. Radiographics. 2006 May-Jun;26(3):745-63. [PubMed: 16702452]

2.

Ghannam MG, Singh P. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 4, 2022. Anatomy, Head and Neck, Salivary Glands. [PubMed: 30855909]

3.

Borle RM, Jadhav A, Bhola N, Hingnikar P, Gaikwad P. Borle’s triangle: A reliable anatomical landmark for ease of identification of facial nerve trunk during parotidectomy. J Oral Biol Craniofac Res. 2019 Jan-Mar;9(1):33-36. [PMC free article: PMC6126203] [PubMed: 30191119]

4.

Martinez-Madrigal F, Micheau C. Histology of the major salivary glands. Am J Surg Pathol. 1989 Oct;13(10):879-99. [PubMed: 2675654]

5.

Carlson GW. The salivary glands. Embryology, anatomy, and surgical applications. Surg Clin North Am. 2000 Feb;80(1):261-73, xii. [PubMed: 10685152]

6.

Abakay MA, Güneş S, Küçük C, Yazıcı ZM, Gülüstan F, Arslan MN, Sayın İ. Accessory Nerve Anatomy in Anterior and Posterior Cervical Triangle: A Fresh Cadaveric Study. Turk Arch Otorhinolaryngol. 2020 Sep;58(3):149-154. [PMC free article: PMC7580510] [PubMed: 33145498]

7.

Procópio Pinheiro R, Gaubeur MA, Itezerote AM, Saleh SO, Hojaij F, Andrade M, Jacomo AL, Akamatsu FE. Anatomical Study of the Innervation of the Masseter Muscle and Its Correlation with Myofascial Trigger Points. J Pain Res. 2020;13:3217-3226. [PMC free article: PMC7719441] [PubMed: 33299345]

8.

Armstrong MA, Turturro MA. Salivary gland emergencies. Emerg Med Clin North Am. 2013 May;31(2):481-99. [PubMed: 23601484]

9.

Plonowska KA, Gurman ZR, Humphrey A, Chang JL, Ryan WR. One-year outcomes of sialendoscopic-assisted salivary duct surgery for sialadenitis without sialolithiasis. Laryngoscope. 2019 Apr;129(4):890-896. [PubMed: 30152080]

10.

Ugga L, Ravanelli M, Pallottino AA, Farina D, Maroldi R. Diagnostic work-up in obstructive and inflammatory salivary gland disorders. Acta Otorhinolaryngol Ital. 2017 Apr;37(2):83-93. [PMC free article: PMC5463527] [PubMed: 28516970]

11.

Wilson KF, Meier JD, Ward PD. Salivary gland disorders. Am Fam Physician. 2014 Jun 01;89(11):882-8. [PubMed: 25077394]

12.

Luers JC, Grosheva M, Reifferscheid V, Stenner M, Beutner D. Sialendoscopy for sialolithiasis: early treatment, better outcome. Head Neck. 2012 Apr;34(4):499-504. [PubMed: 21484927]

Disclosure: Hannah Chason declares no relevant financial relationships with ineligible companies.

Disclosure: Brian Downs declares no relevant financial relationships with ineligible companies.

treatment, symptoms and causes of the disease, diagnostics in the “SM-Clinic”

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• What is atheroma?
• Atheroma symptoms
• Causes of atheroma
• Atheroma diagnostics
• Atheroma treatment
• Doctors

Atheroma can develop on the excretory duct of any sebaceous gland. The sebaceous glands are everywhere except the soles and palms. There are especially many glands on the face, scalp, back between the shoulder blades, chest, and groin. In some areas of the skin, the number of sebaceous glands reaches 900. Therefore, atheroma can have a variety of localization.

Atheroma – a small cavity, not soldered to the skin, easily moves under the skin. Contains a mushy mass, palpable as an elastic, painless ball. This is the result of blockage of the sebaceous gland. Although the excretory duct is blocked, sebum continues to be produced, gradually expanding the duct.

Atheroma increases in size slowly over several years. Patients apply only because of a cosmetic defect, since there are no painful manifestations. Sizes can reach 10 cm or more.

Symptoms of atheroma

A cyst is defined as a soft, round formation that protrudes slightly under the skin. If the contents of the cyst are liquid, then fluctuation (oscillatory movement) is felt. The skin over the atheroma is stretched so much that it cannot be folded. At the top point, a blocked duct can be seen in the form of a black dot. Atheroma is easy to displace relative to neighboring tissues. Education does not give any unpleasant sensations.

If the atheroma is located in a place of close contact with clothing, then scuffs and signs of inflammation may be present.

When located on the scalp, the hair over the atheroma thins and almost always falls out. Due to constant trauma, necrosis (necrosis) often occurs, ulcers form, and slight bleeding occurs. In some patients, the skin over the atheromas on the head becomes dense, cyanotic and painful to the touch.

Causes of atheroma

Blockage of the sebaceous gland occurs for the following reasons:

• genetic – structural features of the sebaceous glands are such that in some glands there is no excretory duct. In this case, the accumulation of sebum begins even in utero, and the born child is covered with atheromas;
• acne, when the mouth of the excretory duct becomes keratinized, and the secretion of the gland becomes more viscous;
• oily seborrhea, when a large amount of sebum forms on the scalp;
• mechanical damage to the gland – boils, cuts, abrasions, scars, permanent hair removal;
• exposure to ionizing radiation;
• ultraviolet irradiation;
• burns and frostbite;
• various hormonal factors resulting from stress.

Usually several pathological mechanisms work simultaneously in one person.

Thus, a blockage can occur for any reason. The resulting secret stretches the duct, and a cavity is obtained. Vessels and nerves are not affected, and the person does not feel anything. However, over time, a dense capsule of connective tissue forms around the swollen cavity. Attempts to puncture and empty the cyst do nothing, as the contents are recruited again and again.

Complicated atheroma is rare, and complications include suppuration. This happens with mechanical pressure or irritation, as well as after independent attempts to empty the cyst. A connective tissue capsule separates the cavity with its contents from the rest of the tissues, and when you try to squeeze it out, it can collapse, and suppuration passes to neighboring areas.

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If you experience these symptoms, we recommend that you make an appointment with your doctor. Timely consultation will prevent negative consequences for your health.

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Diagnosis of atheroma

Diagnosis is carried out by a dermatologist or surgical oncologist. During the examination, the doctor detects characteristic changes, paying attention to the location, mobility and size. The speed at which the cyst formed matters.

In a difficult case, an ultrasound of the soft tissues is performed at the site of the cyst. On ultrasound, a capsule is visible, inside it is a thin cyst and contents. During ultrasound, atheroma is delimited from other similar formations – hygromas (sweat gland cyst), fibromas (connective tissue), lipomas (benign tumor of adipose tissue).

If there is still doubt about the nature of the cyst, a histological analysis (study of the cellular composition) is performed during surgical removal.

Treatment of atheroma

The treatment is complex, since it is necessary not only to remove the cyst with the capsule, but also to choose skin care products to prevent the formation of new cysts.

If the cyst is inflamed, then before surgical treatment, all measures are taken to stop the inflammation. Antibacterial and disinfectants, agents to reduce the formation of sebum are prescribed.

Operative treatment is possible in two variants:

• classical cystectomy — exfoliation of the capsule with a scalpel with a cosmetic suture;
• radio wave removal – high frequency waves evaporate the liquid from the capsule, as a result, the formation is eliminated. This method is preferable because it is not accompanied by bleeding and scarring, but cannot be used in patients with a pacemaker and the presence of metal structures in the body.
• With festering atheroma, pus is first evacuated and the inflammation subsides, and only then the capsule is husked.

The best prevention of atheroma is to see a dermatologist for any skin changes. After the examination, the doctor selects skin care medications that normalize the production of sebum. The entire range of medical services for the diagnosis, treatment and prevention of atheroma is available at the SM-Clinic.

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causes, symptoms of the disease, diagnosis and treatment

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Atheroma: causes, symptoms, diagnosis and treatment.

Definition

Atheroma is a cyst (pathological cavity) of the sebaceous gland, resulting from difficulty or complete cessation of the outflow of secretion (sebum) from the gland. The sebaceous glands are external secretion glands and are located in almost all parts of the skin, with the exception of the palms, soles and back of the feet. The secret produced by them is part of the water-lipid mantle of the skin. If the duct of the gland is clogged, then the secret begins to accumulate in it, stretches it with the formation of a cavity lined with the epidermis and containing the secretion products of the sebaceous gland, cholesterol crystals, keratinized epidermal cells and detritus (decay products) – this is atheroma.

Atheromas occur in 5-10% of the population, mainly formed at the age of 20-30 years, with the same frequency in men and women.

Causes of atheroma

Atheroma occurs as a result of disruption of the sebaceous glands, which is manifested by increased production of sebum and blockage of the duct. A number of factors predispose to this: increased sweating, insufficient hygiene, narrowness of the ducts of the sebaceous glands, individually determined high viscosity of sebum, chronic skin trauma, hormonal disorders, frostbite and burns. Affects the development of atheroma and hereditary factor.

The use of antiperspirants can contribute to blockage of the duct.

Disease classification

Allocate true and false cysts. True sebaceous cysts are a hereditary disease and are extremely rare. They develop as a result of a genetic defect that affects the formation of the gland. Typically, such cysts are found in newborns and are small in size. False cysts are actually atheromas that have arisen due to a violation of the outflow of the secretion of the sebaceous gland.

Symptoms of atheroma

Atheromas most often occur in areas of the body where there are many sebaceous glands, for example, on the scalp, face, neck, in the interscapular space.

Atheroma is a mobile formation of a round or slightly elongated shape, dense or elastic consistency, covered with unchanged skin. A characteristic sign of atheroma, which distinguishes it from other formations, is the presence of a point retraction of the skin (crater) in the area of ​​​​the excretory duct of the gland and adhesion of the skin to the cyst membrane in the same place. Sometimes in the middle of the atheroma there is a hole through which its contents are released – curdled masses with an unpleasant odor.

The size of atheroma can vary from a pea to a chicken egg and even more, reaching 10 cm. Atheroma always rises above the level of the skin, increases slowly, usually painless.

Diagnosis of atheroma

To make a diagnosis, the doctor performs a clinical examination, in some cases an ultrasound examination may be required.

Ultrasound of soft tissues

Examination of soft tissues to detect pathological changes and diagnose neoplasms.

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A biopsy of the formation is rarely performed, since the risk of degeneration of atheroma into a malignant neoplasm is extremely low.

Which doctors to contact

Diagnosis can be made by a dermatologist,
general practitioner or
therapist. Surgical treatment is performed
surgeon.

In order to prevent the appearance of new foci, patients turn to a cosmetologist for a consultation.

Treatment of atheroma

Surgical removal of atheroma together with the capsule gives the best results – this reduces the risk of recurrence. The operation is performed under local anesthesia, usually on an outpatient basis. If the atheroma is located on the face, then sparing methods can be used for aesthetic purposes, such as cystotomy, which involves cutting the skin, opening the atheroma capsule and evacuating the contents of its cavity.

Laser destruction of atheroma is an alternative to surgical removal. There are three methods of laser intervention – laser photocoagulation, laser excision of atheroma together with the shell and laser evaporation of the atheroma shell from the inside. The type of intervention is determined by the surgeon, choosing the most optimal for each individual patient.

Complications

Atheroma may suppurate. This process is accompanied by pain, redness and swelling of the skin. As a rule, the inflammatory process develops slowly. Education is delimited by a capsule, so local and general inflammatory changes during suppuration are poorly expressed. Festering atheroma can spontaneously open with the release of pus with an unpleasant odor.

Atheroma prevention

For prevention, it is recommended to thoroughly cleanse the skin, preventing its pollution and removing excess sebum. If there is a predisposition to the formation of atheromas, it is better to abandon the use of antiperspirants. Beauticians recommend limiting the intake of foods containing a large amount of animal fats and quickly digestible carbohydrates.

Sources:

1. Clinical guidelines “Cysts of the maxillofacial region and neck”. Society of specialists in the field of maxillofacial surgery. 2020.
2. Tarasenko G.N. et al. Atheroma: a problem for a cosmetologist or a dermatologist? // Hospital medicine: science and practice.