Download Parotide gland

Head & Neck Surgery Course
s
e
m
î
N
Salivary Glands: Surgical
anatomy and technique
O
L
R
Dr Pierfrancesco PELLICCIA - Pr Benjamin LALLEMANT
Service ORL et CMF
University Hospital of Nîmes
Introduction
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e
• The Major Salivary Glands
– Parotid
– Submandibular
– Sublingual
O
L
R
• The Minor Salivary Glands
m
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N
Head & Neck Surgery Course
Parotid gland
O
L
R
m
î
N
s
e
Parotid compartment
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e
– Superior – Zygoma
– Posterior – EAC, SCM muscle
L
R
– Inferior – Styloid and digastric
O
– Anterior – mandible, masseter
intern pterygoid muscles
– Lateral – skin and SMAS
m
î
N
Parotid space contents
Nerves
VII, Great Auricular, Auriculotemporal
Blood vessels
L
R
m
î
N
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e
Venous
Retromandibular Vein, Extern Jugular Vein, Intraparotid
Communicant, Superficial Temporal, Intern Maxillary
Arteries
Extern carotid, Superficial Temporal/Transverse Facial,
intern maxillary
O
Lymphatics
Superficial muscular aponeurotic system
(SMAS)
s
e
Continuity with : Superficial temporal
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î
N
fascia, Platysma, galea
O
L
R
Superficial muscular aponeurotic system
SMAS
O
Superficial layer
of deep
cervical fascia
L
R
m
î
N
s
e
Deep neck spaces
• Parotid space
s
e
Parotid gland tumors
• Parapharyngeal Space
L
R
– Prestyloid Compartment
O
deep lobe parotid gland tumors
m
î
N
– Poststyloid Compartment
Paraganglioma, Schwannoma, lymphoma
Parotid Space
Contains:
– External carotid artery
– Posterior facial vein
– Facial nerve
– Lymph nodes
O
L
R
– Auricolotemporal nerve (V3)
m
î
N
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Parapharyngeal space
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• Boundaries
– Superior—skull base
– Inferior—hyoid
L
R
– Anterior—ptyergomandibular raphe
O
– Posterior—prevertebral fascia
m
î
N
– Medial—buccopharyngeal fascia
– Lateral—superficial layer of deep fascia
Parapharyngeal space
– Prestyloid
• between tonsillar fossa and
medial pterygoid
• Contenents:
– fat
– connective tissue
– nodes
– Poststyloid
O
L
R
• Contenents:
– Carotid sheath
– Cranial nerves IX, X,
XI, XII
– Sympathetic chain
m
î
N
s
e
Parapharyngeal space
Stylopharyngeal
aponeurosis
O
L
R
Stylohyoidien
stylopharyngeal ,
and styloglossus muscles
m
î
N
s
e
Parapharyngeal space
Stylomandibular
Tunnel
O
L
R
m
î
N
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e
Facial nerve: introduction
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m
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N
– Pes Anserinus – 1.3 cm
O
L
R
– Temperofacial Division
– Cervicofacial Division
– 5 Terminal branches
Parotid space : major structures
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e
• Parotide gland
• Nerves
L
R
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N
• Blood vessels
O
• Lymphatics
Parotid Gland
• Major salivary gland
• Production of Saliva
O
• 2 lobes
– Superficial
– Deep
L
R
m
î
N
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e
Parotid Gland
• Superficial lobe: 80%,
overlies Masseter &
Mandible
• Deep lobe: 20%,
Retromandibular
O
L
R
• Stylomandibular Tunnel,
Isthmus of Parotid
m
î
N
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e
Parotid Gland
Salivary tissue
Salivary ducts
O
L
R
 Stensen’s duct
m
î
N
s
e
Stensen’s Duct
s
e
– Arises from anterior border
– 1.5 cm inferior to Zygomatic
arch
O
L
R
– Pierces Buccinator at 2nd
Molar
– 4-6 cm in length, 5 mm in
diameter
m
î
N
Stensen’s Duct
O
L
R
m
î
N
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Facial nerve: anatomy
O
L
R
m
î
N
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Facial nerve: anatomy
O
L
R
m
î
N
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Facial nerve: physiology
Motor innervation
O
L
R
m
î
N
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Facial nerve: physiology
• Sensory innervation
O
L
R
• Parasympathetic
innervation
m
î
N
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e
Other nerves
Great Auricular nerve
• Cervical plexus
L
R
m
î
N
Auriculo-temporal nerve
O
• Superficial Temporal vessels
• Frey’s Syndrome
s
e
Great auriculo-temporal nerve
O
L
R
m
î
N
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e
Auriculo-temporal nerve
O
L
R
m
î
N
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e
Blood Vessels
O
L
R
m
î
N
s
e
Nerfs and Blood Vessels
relationship (posterolateral view)
O
L
R
m
î
N
s
e
Nerfs and Blood Vessels
relationship (lateral view)
O
L
R
m
î
N
s
e
Lymphatics
– Paraparotid & Intraparotid nodes
– Superficial & Deep Cervical nodes
s
e
(1st echelon nodes : levels II-III; then levels IV and V)
O
L
R
m
î
N
Lymphatics
O
L
R
m
î
N
s
e
Head & Neck Surgery Course
s
e
m
î
N
Parotidectomy
surgical technique
O
L
R
Dr Pierfrancesco PELLICCIA - Pr Benjamin LALLEMANT
Service ORL et CMF
University Hospital of Nîmes
Parotidectomy
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Superficial portion
O
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R
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î
N
O
L
R
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N
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e
O
L
R
m
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N
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Localization of CN VII
– Tragal pointer
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N
– Tympanomastoid suture
L
R
– Posterior belly Digastric
O
– Styloid process
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e
O
L
R
m
î
N
s
e
O
L
R
m
î
N
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O
L
R
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N
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Bleeding that announces FN
O
L
R
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î
N
s
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O
L
R
m
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N
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O
L
R
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î
N
s
e
O
L
R
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N
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O
L
R
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î
N
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Parotidectomy
Deep portion
O
L
R
m
î
N
s
e
O
L
R
m
î
N
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e
Head & Neck Surgery Course
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Submandibular gland
O
L
R
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î
N
Submandibular Gland
• Major salivary gland
m
î
N
• Salivary tissue + salivary ducts
O
L
R
 Warthon’s duct
s
e
• Level Ib: submandibular space
Submandibular space
(level Ib)
O
L
R
m
î
N
s
e
Submandibular Space
s
e
Boundaries
– Superior – oral mucosa
m
î
N
– Inferior - superficial layer of deep
fascia
O
L
R
– Anterior border – mandible
– Lateral border - mandible
– Posterior - hyoid and base of
tongue musculature
Submandibular Space
Sublingual space
• Contenents
– Areolar tissue
– XII and lingual nerves
L
R
– Sublingual gland
– Wharton’s duct
O
Submaxillary space
m
î
N
– Submental (level Ia)
– Submaxillary (level IB)
• Contenents
– Submandibular gland
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e
Submandibular Space
O
L
R
m
î
N
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Wharton’s duct
– Exits medial surface
– Between Mylohyoid &
Hyoglossus
O
– 5 cm in length
L
R
– Lingual nerve & CN XII
m
î
N
s
e
Wharton’s duct
O
L
R
m
î
N
s
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Wharton’s duct
O
L
R
m
î
N
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Arterial & venous supply
Artery: Submental branch of Facial artery
Vein: Anterior Facial vein
O
L
R
m
î
N
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e
Arterial & venous supply
O
L
R
m
î
N
s
e
Lymphatics
levels Ib, II, III
O
L
R
m
î
N
s
e
Nerves
• Innervation
s
e
– Lingual nerve and
Submandibular Ganglion
O
L
R
m
î
N
– Superior Cervical Ganglion
(symp)
• Other nerves
– XII
– Marginal mandibular branch
Innervation
O
L
R
s
e
m
î
N
• Superior Cervical
Ganglion (symp)
• Submandibular Ganglion
(para)
Hypoglossal nerve (XII)
and lingual nerves
O
L
R
m
î
N
s
e
Marginal Mandibular branch
•
Most commonly injury dissection level Ib
•
Landmark
– 1cm anterior and inferior to angle of
mandible
L
R
•
Subplatysmal
•
Deep to fascia of the submandibular
gland
O
•
Superficial to facial vein
•
More than one branch often present
m
î
N
s
e
Marginal Mandibular branch
O
L
R
m
î
N
s
e
Head & Neck Surgery Course
s
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Submandibulectomy
Surgical technique
O
L
R
m
î
N
O
L
R
m
î
N
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O
L
R
m
î
N
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O
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N
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O
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N
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O
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N
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O
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N
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N
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N
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