The salivary glands

The parotid glands are the largest salivary glands. They are wedge-shaped and situated in front of the
ear and behind the ramus of the mandible. The apex of the wedge is the deepest part of the gland. The
peripheral branches of the facial nerve (CN VII) are intimately associated with the parotid gland. This
relationship is inadvertently demonstrated when an inferior dental nerve anaesthetic block is administered
incorrectly, and causes a temporary drooping of the upper eye lid.
Parotid saliva is transferred along the parotid duct into the oral cavity. The thick-walled parotid duct
(Stenson's duct) emerges at the anterior border of the parotid gland and runs over the surface of the masseter
before hooking medially over the anterior muscle border. The orifice of the duct is covered by a small flap
of mucosa called the parotid papilla and this is situated opposite the maxillary second permanent molar.
The two submandibular glands are approximately half the size of the parotids. The superficial part of
the submandibular gland is wedged between the body of the mandible and the mylohyoid muscle, with the
smaller deep part hooking around the posterior border of the muscle to lie on the floor of the mouth above
the mylohyoid. The submandibular (Wharton's) duct runs forward, along the floor of the mouth to open into
the subligual papilla, just lateral to the lingual frenum. The secretions are a mixture of serous and mucous
fluids.
The sublingual glands are the smallest of the three pairs of salivary glands and are located just below
the floor of the mouth beneath the sublingual folds of mucous membrane. There are numerous sublingual
ducts that open into the mouth along the sublingual folds. The secretions of these glands are predominantly
mucous. The minor salivary glands consist of numerous small mucosal glands situated on the tongue, palate,
buccal and labial mucosa. They produce primarily a mucous secretion.

Assessment of the salivary glands

Examination

The parotid glands, lying partially concealed by the ascending ramus of the mandible, are not
particularly easy to palpate. Tenderness and swelling are best detected by standing in front of the patient and
by placing two or three fingers over the posterior border of the ascending ramus of the mandible. Backwards
and inwards movement of the fingers with light pressure is almost always all that is needed to detect
tenderness in the superficial part of the parotid. This manoeuvre is necessary to differentiate parotid
tenderness from that of the temporomandibular joint or the masseter with which it is often confused. It must
also be remembered that the painful signs resulting from temporomandibular joint/muscle dysfunction may
extend to the upper pole of the parotid with which the joint is in close anatomical relationship. Swelling of a
parotid gland may also be visualized by standing behind the patient who is seated in a reclined dental chair.
When examining a parotid gland the duct papilla must also be examined intraorally for signs of
inflammatory change. Parotid saliva can be visualized by lightly compressing the skin overlying the duct
with the fingers. If the cheek is held retracted, the saliva expressed by this manoeuvre will be seen coursing
downwards over the buccal mucosa from the duct papilla. It is helpful for the clinician to know that parotid
saliva can expressed, but this method is not of value in quantitatively assessing the parotid flow rate of
saliva.
The submandibular gland may be felt below the angle and body of the mandible, this simple
palpation being reinforced by bimanual palpation with a finger in the floor of the mouth, gentle pressure
being exerted between the examining hand (below the mandible) and the finger. As in the case of the parotid
gland, the submandibular (Wharton's) duct should be observed for signs of inflammation and a subjective
assessment made of the quality of the saliva. It is similarly difficult to specify the normal palpation features
of the submandibular gland. In some entirely normal individuals it is possible to palpate the gland, while in
others it is not.

References :

Field A , Longman L. Tyldesley’s oral medicine. 5th Ed. Oxford University Press; 2003