Parotid and Salivary gland Surgery

Salivary Glands

The Salivary Glands produce saliva which moistens food to facilitate chewing and swallowing. Saliva contains enzymes which initiate the digestion process by breaking down food before it reaches the stomach. In addition, saliva cleanses the mouth by washing away bacteria and food particles, and thus, helps prevent tooth decay.

The Salivary Glands empty saliva into the mouth, through ducts that open at various locations in the mouth. There are three pairs of major (large) Salivary Glands. In addition, there are many tiny glands called minor Salivary Glands located in the lips, inner cheek area (buccal mucosa), and extensively in other linings of the mouth and throat.

The major Salivary Glands are:

Parotid Glands
The two Parotid Glands are located in front of the ears, in the cheeks. These are the largest Salivary Glands.

Submandibular Glands
The two Submandibular Glands are located under the jaw, in the upper neck.

Sublingual Glands
The two Sublingual Glands are the smallest major Salivary Glands and are located under the tongue, in the front of the mouth.

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Salivary Gland Disorders

There are several Salivary Gland disorders. Some Salivary Gland disorders may impede the Salivary Glands from functioning properly while other Salivary Gland disorders may affect one's overall health. Most of the Salivary Gland disorders are cause by Salivary Gland Stones, infection, cysts and tumors.

Salivary Gland Stones (Sialolithiasis)

Deposits of calcium within the Salivary Glands can result in the formation of Salivary Gland Stones (Sialolithiasis). Salivary Gland Stones are most often found in the Submandibular Glands, but the Parotid Glands are also commonly affected. The exact cause of calcium deposition and Salivary Gland Stone formations is unknown. However, it is known that dehydration, which results in thickened saliva, increases the risk of stone formation. In addition, reduced food intake and certain medications also result in reduced saliva production, thus increasing the risk of stone formation.
- Symptoms
  
  Salivary Gland Stones commonly occur in the Submandibular and Parotid Glands, resulting in the obstruction of the flow of saliva. Symptoms typically occur while eating. Saliva production starts to flow with eating, but cannot exit the gland, and thus leads to pain and swelling of the involved gland. Often, the swelling gradually subsides, only to swell again with the next meal. Occasionally, an infection can develop in the pool of blocked saliva, leading to more pain and swelling in the glands.
- Diagnostic Studies
  
  A stone may be diagnosed based on the presenting symptoms and physical examination and palpation of a stone in the gland by the physician. A CT scan can be used confirm the diagnosis.
- Treatment
  
  The goal of treatment is to remove the stone. Often, the stone can be flushed out by increasing the flow of saliva with sour candy or citrus foods (which stimulate the flow of saliva) combined with increased fluid intake and massaging the gland. If this fails, stones that are near the outer most portion of the duct can be squeezed out by a physician. In some cases, the stone may need to be surgically removed. Stones that are deep in the gland may require the entire gland to be removed.
Salivary Gland Infection (Sialadenitis)

Salivary Gland Infection in adults is often due to obstruction of the gland (by a stone or tumor), poor oral hygiene or dehydration. The infections in adults are usually caused by bacteria.
- Symptoms
  
  Infection results in a painful swelling of the gland involved. There is often redness of the overlying skin and it is not uncommon to have fever.
- Diagnostic Studies
  
  Salivary Gland Infections are usually diagnosed based on the presenting symptoms and physical examination. Culture of the pus from the gland's duct can be sent to identify the type of bacteria causing the infection. In addition, a CT scan or ultrasound may be done to rule out an abscess. If the symptoms persist, imaging of the neck is usually recommended to rule out an underlying source for the infection (such as a stone or tumor).
- Treatment
  
  Bacterial infections respond well to antibiotics, warm compresses to the affected area and increasing salivary flow in order to flush out the infection. The flow of saliva can be increased with sour candy or citrus foods combined with increased fluid intake and massaging the gland. If there is an abscess, surgical drainage or aspiration is often required.
  
  The Salivary Gland may scar with recurrent infections, resulting in permanent narrowing of the gland's drainage ducts. Patients that develop such narrowing of the gland's drainage ducts may develop chronic or recurrent infections that may not respond to antibiotics. Surgical removal of the gland is recommended in patients with recurrent or chronic infections that fail to resolve with antibiotic therapy.
Salivary Gland Cyst (Sialocele, Mucocele, Oral Ranula and Cervical Ranula)

Salivary Gland Cysts occur as the result of trauma or obstruction to the Salivary Gland excretory duct and spillage of saliva into the surrounding soft tissue. The blocked duct does not allow the saliva to exit into the mouth. The saliva, therefore, gets backed up in the gland and results in the enlargement and ballooning of the gland. Salivary Gland Cysts can be classified as Sialocele, Mucocele, Oral Ranula, and Cervical Ranula.
- Sialocele
  Sialoceles are cysts of major Salivary Gland origin. Sialoceles are painless swellings of a major salivary gland.
- Mucocele
  Mucoceles are cysts of minor Salivary Gland origin. Mucoceles are painless, asymptomatic swellings that have a relatively rapid onset and fluctuate in size.
- Oral Ranula
  Oral Ranulas are painless cysts that occur in the floor of the mouth and usually involve the major Salivary Glands. They do not extend beyond the mouth. Oral Ranulas usually present with swelling in the floor of the mouth that is painless. On occasion, they can interfere with speech or chewing.
- Cervical Ranula
  Cervical Ranulas (also known as Plunging Ranulas) are cysts that occur in the floor of the mouth and extend (plunge) into the neck. Cervical Ranulas usually present as a painless swelling in the neck.
  
  Mucoceles are cysts of minor Salivary Gland origin. Mucoceles are painless, asymptomatic swellings that have a relatively rapid onset and fluctuate in size.
Diagnostic Studies

Simple cysts and Mucoceles are usually diagnosed with a physical examination and rarely require further diagnostic testing. Imaging of the head and neck by CT scanning or an MRI is recommended to determine the extent of a Cervical Ranula and to eliminate other disease processes prior to surgical intervention.
Treatment

Occasionally, Salivary Cysts spontaneously resolve, especially in infants and young children. Although aspiration of Salivary Cysts does deflate them, this is temporary and almost all cysts return after aspiration. Small and asymptomatic Salivary Cysts can be observed.

Sialoceles
Asymptomatic Sialoceles can be observed. However if Sialoceles become symptomatic (obstruct salivary flow or get infected) or become cosmetically noticeable, surgical excision is recommended. Surgical excision usually involves removal of the Salivary Gland that contains the Cyst (see below).
Mucoceles
If the Mucocele is small and superficial, it may respond to topical steroid treatment. Larger Mucoceles require surgical removal for definitive treatment.
Oral Ranulas
The preferred method of treatment of Oral Ranulas is complete excision of the Ranula and the associated sublingual gland. Drainage, marsupialization and excision of the Ranula without the excision of the associated sublingual gland results in a high rate of recurrence of the Ranula.
Cervical Ranulas
The preferred method of treatment of Cervical Ranulas is the complete surgical excision of the oral portion of the Ranula with the associated sublingual Salivary Gland and drainage of the cervical cyst. The most important factor in surgical management for Cervical Ranulas is removal of the responsible major Salivary Gland.

Salivary Gland Tumors

Salivary Gland Tumors are growths in the Salivary Glands. There are many different types of tumors which can develop in these glands, some non-cancerous (benign) and others cancerous. All Salivary Glands can develop tumors; however some are more prone than others. For example the majority of tumors are seen in the Parotid Gland. In addition, some glands tend to develop benign tumors while others are more likely to develop a cancerous tumor. For example, 80% of Parotid Gland Tumors are benign, while 50% of Submandibular Tumors and only 35% of Sublingual Gland Tumors are benign.

Causes

Although the causes of Salivary Gland Cancer are not clear, certain risk factors have been associated with increased chance of developing Salivary Gland Cancer. These risk factors include:
- Age - Salivary Gland Cancer can occur in people of all ages; however, it is more likely to occur in older adults.
- Radiation exposure - Sources of such radiation include medical treatments of the head and neck and radiation fallout from power plant accidents or nuclear weapons.
- Chemical exposure – Constant exposure to certain industrial chemicals, pesticides or sawdust has been associated with an increased risk of developing various types of Salivary Gland Cancer.
Types of Salivary Gland Cancer

The majority of Salivary Gland Tumors are non-cancerous (benign). These growths do not spread to other parts of the body and are rarely life-threatening. There are several types of benign Salivary Gland Tumors and they include Pleomorphic Adenoma, Warthin tumors and Oncocytomas.

There are many types of Salivary Gland Cancers. Salivary Glands are made up of many different kinds of cells and Salivary Gland Cancer can arise from any of these cell types. The rate that the cancer grows and spreads depends on the type of cancer. These cancers include Mucoepidermoid, Acinic Cell, Carcinoma Ex-Pleomorphic, Adenoid Cystic and Squamous Cell cancer.
Symptoms

The most common symptom is a painless mass. Often, Salivary Gland Tumors may not cause any symptoms. They are frequently found during a physical examination or incidentally noted on an imaging study done for another reason. Symptoms that may present include:
- A painless growth in the area of the ear, cheek, jaw, lip, or inside the mouth.
- Difficulty swallowing or opening the mouth widely.
- Weakness or numbness in the face.
- Facial or oral pain that does not go away.
Diagnostic Testing

Imaging of the neck with an MRI or CT scan helps identify the extent of growth and involvement of surrounding structures.

Fine needle aspiration biopsy is often used to determine whether the salivary growth is cancerous. The biopsy samples the cells in the area of concern which are then sent to a pathologist for analysis. During the procedure, a thin needle is inserted through the skin into the salivary mass to collect a sample of cells. Multiple samples are usually taken to ensure an accurate analysis. Ultrasound technology can be used to visualize masses which are difficult to find and to guide the placement of the needle. Fine needle aspiration biopsy is carried out in the office by Dr. Zadeh. The samples of cells are then sent to a pathologist for evaluation.
Treatment

The type of treatment varies based on the patient, location of the tumor and type of tumor. Treatment options include observation, surgical removal, radiation therapy and chemotherapy.

Surgical excision of the tumor with the involved Salivary Gland is a common treatment for Salivary Gland Tumors (see below). Because the glands are numerous, removal of one of the salivary glands does not typically cause any noticeable decrease in saliva production. The nerves that control the motion of the facial muscles lie in close proximity or are within the salivary glands. Dr. Zadeh uses facial nerve monitoring equipment and delicate and meticulous dissection techniques to minimize the risk of any trauma to these important nerves during the procedure. Dr. Zadeh also uses cosmetic surgery principles to disguise the incision scar.

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Laryngeal nerve monitor

Submandibular Gland Surgery

Submandibular Gland Surgery involves removal of the entire Submandibular Gland. This surgery is commonly performed to treat Submandibular Gland tumors and stones. In addition, a chronic infection of the Submandibular Glands that fails to respond to medications is often treated with surgical removal. A small incision is made below the jaw line in the neck. The gland is then removed through this small incision, while preserving surrounding tissues, nerves and vessels.

Dr. Zadeh uses facial nerve monitoring equipment and delicate and meticulous dissection techniques to minimize the risk of any trauma to these important structures during the procedure. Dr. Zadeh also uses cosmetic surgery principles to disguise the incision scar. Submandibular Gland Surgery is an outpatient procedure and most patients are able to go home a few hours after surgery.

Parotid Gland Surgery (Parotidectomy)

The surgery to remove the Parotid Gland is called a Parotidectomy. This surgery involves removing either part or all of the Parotid Gland. This surgery is commonly performed to treat Parotid Gland Tumors and stones. In addition, a chronic infection of the Parotid Gland that fails to respond to medications is often treated with surgical removal. A skin incision is made, which runs from the front of the ear, curving towards the back of the ear, to the level of the hair line. This incision is very similar to that used in face-lift surgery and has excellent cosmetic results. An important part of the surgery is identification and preservation of the facial nerve which runs through the Parotid Gland and controls movement of the face.

Dr. Zadeh uses facial nerve monitoring equipment and delicate and meticulous dissection techniques to minimize the risk of any trauma to this important nerve during the procedure. Dr. Zadeh also uses cosmetic surgery principles to disguise the incision scar. Parotid Gland Surgery is an outpatient procedure and most patients are able to go home a few hours after surgery.