Imaging and radiological diagnostic methods
The diagnosis of salivary gland pathologies (including the need to differentiate tumors from sialolithiasis) relies on a range of radiological methods. Plain radiography is not always effective, as shadows may overlap with facial skeleton bones, and some stones are poorly radiopaque.
Special positioning techniques are used for precise localization:
- V.G. Ginzburg's method: for the submandibular gland, rays are directed from top to bottom between the jaws with the mouth opened as wide as possible.
- A.A. Kyandsky's method: radiography of the floor of the oral cavity to assess the anterior part of the submandibular duct.
- M.R. Abdusalamov's positioning: film between the teeth and the soft palate, tube on the chest — for visualizing intra-glandular sections.
A more detailed picture is provided by:
- Sialography: ducts are filled with a water-soluble contrast agent (iohexol, sodium amidotrizoate). Radiolucent elements appear as filling defects.
- Computed sialotomography: allows the detection of any stones and the 3D modeling of tissue structure, which is critically important before surgery.
- Echosialography (Ultrasound): captures the reflection of ultrasonic waves. Dense structures create a "sound track" whose width precisely indicates the size of the object.
Functional and laboratory tests
Functional tests are used to assess the performance of the parenchyma and ductal system:
- Sialometry. Measurement of secretion volume over a fixed time. Collection is performed using Lashley–Krasnogorsky capsules or catheters of appropriate diameter. In pathologies, secretion drops sharply.
- Scintigraphy. Assesses the rate of radiopharmaceutical uptake from the blood. The faster the gland captures the isotope, the higher its functional activity.
- Cytological examination. Analysis of the cellular composition of the secretion. If the obstruction (e.g., a stone) is located within the gland itself, neutrophils, erythrocytes, and columnar epithelium predominate in the saliva. When localized in the duct, the cellular composition is sparse, with predominant squamous epithelium. During exacerbation of inflammation, the cell count increases sharply.
Surgical tactics and gland injuries
Surgical interventions on the salivary glands, including the removal of tumors and stones, are fraught with a number of specific complications. Extirpation (complete removal) of the gland is considered a highly undesirable measure, as the lost endocrine and exocrine functions are not compensated by the remaining glands.
Main complications of surgical treatment:
- Nerve damage: during parotid gland surgery, the branches of the facial nerve (n. facialis) are at risk. Compression from edema causes temporary conduction impairment, while transection causes permanent impairment. During submandibular gland interventions, the marginal mandibular branch of the facial nerve (leading to a loss of tone in the depressor anguli oris muscle), as well as the lingual (n. lingualis) and hypoglossal (n. hypoglossus) nerves, may be damaged.
- Salivary fistulas: external (saliva leaks onto the skin) and internal (the orifice opens into the oral cavity). They often form after surgeries using an external approach.
- Cicatricial strictures: narrowing of the ducts requiring plastic surgery (creation of a new orifice) or, if ineffective, removal of the gland.
In case of damage to the parenchyma or duct during dental procedures, opening of phlegmons, or tumor removal, the clinical picture depends on the nature of the wound and localization.
Management of comorbid conditions
If differential diagnosis indicates sialolithiasis, conservative treatment (bougienage with sialagogues) is effective only for small calculi located near the orifice.
Surgical approaches vary:
- Intraoral flap incisions according to Afanasyev–Starodubtsev for the parotid duct.
- Extraoral approaches with skin-fat flap reflection according to Kovtunovich–Klementov for the parotid gland itself.
A modern alternative is extracorporeal shock wave lithotripsy (ESWL). Shock waves fracture stones of any size, but the method is applicable only when secret drainage is preserved (absence of strictures).
Briefly: answers to topical questions
What types of benign tumors are most commonly found in the salivary glands?
Benign epithelial salivary gland tumors include:
- Pleomorphic adenoma (mixed tumor) — most frequently localized in the parotid salivary gland.
- Warthin tumor (adenolymphoma) — a rare tumor, occurring in about 6% of cases.
- Myoepithelioma (myoepithelial adenoma).
- Oncocytoma (oncocytic adenoma) — a rare tumor, predominantly of the parotid gland.
- Basal cell adenoma.
- Canalicular adenoma.
- Sebaceous adenoma.
- Ductal papilloma.
- Cystadenoma.
What malignant neoplasms are typical for major and minor salivary glands?
The most common malignant salivary gland tumor is mucoepidermoid carcinoma. The second most frequent is adenoid cystic carcinoma, typical for the minor palatine and parotid salivary glands. Malignant epithelial neoplasms (cancers) include:
- Mucoepidermoid carcinoma — the most frequent form, affecting predominantly the parotid gland.
- Adenoid cystic carcinoma (cylindroma).
- Acinic cell carcinoma.
- Epithelial-myoepithelial carcinoma.
- Adenocarcinoma (including basal cell, mucinous, sebaceous, and pleomorphic low-grade).
- Papillary cystadenocarcinoma.
- Oncocytic carcinoma.
- Salivary duct carcinoma.
- Malignant myoepithelioma (myoepithelial carcinoma).
- Carcinoma ex pleomorphic adenoma.
- Squamous cell carcinoma.
- Small cell carcinoma.
- Undifferentiated carcinoma.
What are the indications for salivary gland extirpation?
Extirpation of a salivary gland for sialolithiasis is strictly indicated in the presence of two conditions:
- Frequent recurrence of the disease.
- Inability to surgically remove the salivary stone.
In case of recurrent stone formation after spontaneous passage of the stone, surgical removal, or extracorporeal shock wave lithotripsy, removal of the salivary gland is recommended.
For malignant neoplasms, radical intervention involves the en bloc removal of the affected gland along with regional lymph nodes.
In ranula, the best results are achieved by en bloc excision of the cyst along with the sublingual salivary gland.
What specific complications may arise following parotid gland removal (parotidectomy)?
Neurological disorders, infections, and fistulae may occur after parotidectomy. Specific complications include:
- Injury to the branches of the facial nerve (n. facialis) leads to facial muscle paresis. Permanent impairment occurs with anatomical transection of the nerve, while temporary impairment results from compression by edematous tissue or stretching during blunt wound expansion.
- Frey's syndrome (auriculotemporal syndrome) is pathological sweating in the cheek area during mastication due to damage to the auriculotemporal nerve.
- External salivary fistulae present a surgical challenge and require specialized closure procedures.
- Infection may originate from a poorly ligated duct stump.
- Retained calculus in the duct stump or surrounding tissues in sialolithiasis.
Class and exam questions
Which diseases are differentiated from salivary gland tumors?
With non-calculous sialadenitis, sialolithiasis, cysts, lymphadenitis, and mandibular osteoma.
In which cases is salivary gland extirpation indicated?
Gland removal is indicated only in cases of frequent recurrence of the pathological process and the impossibility of surgical stone removal.
What happens when the marginal mandibular branch of the facial nerve is damaged?
This leads to a loss of tone in the depressor anguli oris muscle.
What else to study on this topic
- Afanasyev–Starodubtsev intraoral approach technique
- Kovtunovich–Klementov extraoral approach
- Extracorporeal shock wave lithotripsy technique (Minilith, Modulith SLX devices)
- Principles of forming a new duct orifice in strictures
- Features of using Lashley–Yushchenko–Krasnogorsky cups
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