Projection of the excretory duct of the parotid gland. Tumors of the parotid salivary gland. The structure of the salivary glands

Humans have 3 pairs of salivary glands.

They are found under the jaw, tongue and near the ears.

The largest of these are the parotid salivary glands.

They contribute to the flow of the most important processes - protein and mineral metabolism, are glands of external secretion.

The parotid glands are located near the ears, in the chewing region of the face, in the anterior part below the auricles, continue on the lateral surface of the lower jaw, at the posterior edge of the masticatory muscle.

Organ of irregular shape, gray-pink color. Its mass does not exceed 30 gr. The content of the gland is in a thin capsule, which has an uneven density. Some parts of it are loose. The capsule in some places grows into the gland and divides it into lobules.

Location and structure of the salivary glands

Therefore, it has a cellular structure. The excretory duct of the parotid salivary gland opens at the level of the second upper molar.

The glands have two vulnerabilities: in the back near the ear canal and deep inside. In these areas, pus comes out during inflammation.

Functions

The parotid salivary glands are involved in important life processes.

Salivary gland disease - sialadenitis. Most often it is unilateral. Inflammation is caused by bacteria and viruses. It can occur in acute and chronic form. Its character depends on the type of sialadenitis.

Sharp contact. Occurs if a purulent inflammation has formed near the gland. For example, a furuncle.
Blockage of the duct of the salivary gland. It is formed due to the ingress of a foreign body into the duct: particles of food, villi from a toothbrush.
Parotitis. It is characterized by swelling of the cheeks and neck.
Acute lymphatic. With it, the gland and lymph nodes, subcutaneous tissue are affected.
Chronic interstitial. Occurs after surgery or past infections. It runs painlessly.
Chronic parenchymal. It is provoked by cystic formations in the tissues of the gland. Has a painless course.

The most common is the mumps virus. In the people, this disease is called mumps. The infection causes malfunction of the body. Saliva with it is secreted in smaller quantities, which has a bad effect on digestion.

With parotitis, intoxication of the body occurs, which can lead to fever. The causative agent is a virus that can stick together and destroy red blood cells. It easily penetrates the upper respiratory tract, affecting them.

inflamed gland

They get sick with mumps mainly in the cold season, because. the virus "loves" low temperatures, survives at them for several months. Most often, parotitis affects children from 3 to 10 years. After recovery, immunity to mumps is developed, which is able to protect the body from re-infection for 20 years. Over time, there is a risk of re-infection.

The virus does not manifest itself in any way from 10 to 26 days, but during this period, not knowing about the disease, it is easy to infect others. Parotitis is transmitted by airborne droplets. During the incubation period, the virus actively multiplies and, as soon as the number of microorganisms reaches a maximum, it penetrates into the blood.

Inflammation manifests itself as pain in the parotid salivary glands on one or both sides. Gradually, other symptoms of infection appear:

dry mouth;
swelling of the face;
heat;
thick and cloudy saliva;
unpleasant taste in the mouth;
purulent discharge;
pain when chewing and swallowing food;
loss of appetite;
pressure in the neck;
pain radiates to the ears, nose, neck.

The patient is shown bed rest. Recovery occurs depending on the form of the disease - mild, moderate or severe. The severity of symptoms and the duration of parotitis depend on this.

Other diseases

Inflammation of the gland can be a sign not only of mumps, but also of autoimmune diseases.

They develop as a result of abnormal production of antibodies. The virus, getting into the cells, changes their structure. Organ tissues are gradually destroyed.

Their altered cells are perceived by the body as foreign and "take up arms" against them, producing antibodies.

As a result of the autoimmune process, lymphoid cells accumulate in the organ. This condition is called Sjögren's syndrome. Viral infections are to blame, along with a genetic predisposition.

The parotid salivary glands are susceptible to the formation of stones in the salivary duct - salivary stone disease. With this pathology, reactive inflammation occurs in the organ. Stones interfere with the outflow of saliva. This can provoke the appearance of a retention cyst.

Mucoepidermoid carcinoma

Malfunctions in the work of the organ can provoke a tumor of the parotid salivary gland. The most common benign neoplasm is a pleomorphic adenoma of the parotid salivary gland. It is painless, grows slowly, and is common in the elderly. Education must be removed in time, because. it can reach enormous proportions.

Of the malignant tumors, the most common is mucoepidermoid carcinoma. Most often occurs in women aged 50-60 years. The prognosis after surgery depends on the degree of spread of the tumor and the depth of growth.

Why is it inflamed?

Inflammation triggers are:

infectious diseases;
operations;
systematic playing on wind instruments;
high blood pressure;
narrowing of the duct.

Parotitis is a childhood disease. It rarely affects an adult. Epidemics of the disease are observed in cold weather, cover kindergartens and schools.

The disease is diagnosed by palpation of the organ, sometimes an ultrasound, x-ray or MRI of the glands is prescribed.

Treatment

In mild and moderate forms of inflammation of the glands, bed rest must be observed. To relieve symptoms, prescribe:

antipyretic;
painkillers;
dry warm compresses - allowed at body temperature not higher than 37.2;
compliance with the drinking regime - lack of fluid can aggravate the situation;
a special diet - the use of fermented milk products and fiber, give preference to grated food;
meticulous oral hygiene - after each meal, rinse your mouth with soda solution;
decoctions of herbs, wild rose;
sometimes physiotherapy is used to alleviate the condition.

With complex forms of inflammation, the patient is treated in a hospital.

If the disease is neglected and it comes to the appearance of purulent masses, they turn to the surgeon. He opens the gland and removes the contents. The condition improves and within two weeks, there is a complete recovery.

Complications

The risk of complications is high if treatment is not started on time.

The most serious are:

breakthrough of pus into the external auditory canal;
melting of the walls of large vessels, which leads to bleeding;
parotid hyperhidrosis;
swelling and suppuration of surrounding tissues;
blockage of the salivary duct, leading to the formation of fistulas.

For men, parotitis is especially dangerous, because. can cause testicular atrophy, leading to infertility.

In severe cases, complete removal of the salivary gland is required.

Prevention

To avoid inflammation of the organ, you must:

observe oral hygiene;
strengthen immunity;
visit the dentist regularly;
do not start the treatment of infections and colds.

Acidic fruits and vegetables help prevent congestion in the salivary glands. Periodic resorption, for example, lemon slices contributes to the outflow of saliva.

Ignoring the symptoms of inflammation of the glands leads to chronic sialadenitis. Exacerbation can provoke any infection.

In medicine, there are no drugs yet that could fight viruses that cause inflammation of the parotid salivary glands.

Only antibodies produced by the immune system can fight it.

An excellent prevention of mumps is a vaccine against the pathogen. Children are vaccinated at 1, 6 and 15 years of age. In adulthood, vaccination is carried out every 10 years. The three-component vaccination against measles, rubella and mumps is well tolerated.

Normally, saliva production occurs without stopping. provoke disturbances in the production of saliva, for this reason the digestive system as a whole suffers.

We will consider methods for treating inflammation of the salivary glands.

Vaccination significantly reduces the risk of getting mumps. If the virus still enters the body, then the disease proceeds in a mild form, without complications.

When anxiety symptoms appear, see a therapist. If a patient is diagnosed with mumps, he will be referred to an infectious disease specialist. The disease is quickly transmitted to others, so those in contact with the patient will need to see a doctor.

Types and functions

There are several classifications.

By size, glandulae salivariae are:

large;
small.

By the nature of the allocated secret:

serous - saliva is enriched with a large amount of protein;
mucous - the secret contains mainly a mucous component;
mixed - they can secrete serous and mucous secretions.

The main function of the glandulae salivariae is the production of saliva.

Saliva is a clear, slightly viscous, slightly alkaline substance. More than 99.5% of its composition is water. The remaining 0.5% are salts, enzymes (lipase, maltase, peptidase, etc.), mucin (mucus), lysozyme (antibacterial substance).

All functions of saliva are divided into 2 types - digestive and non-digestive. Digestives include:

enzymatic (the breakdown of certain substances, for example, complex carbohydrates, begins in the mouth);
the formation of a food bolus;
thermoregulatory (cooling or heating food to body temperature).

Non-Digestive Functions:

moisturizing;
bactericidal;
participation in the mineralization of teeth, maintaining a certain composition of tooth enamel.

Note. The study of the function of glandulae salivariae was carried out by Academician Pavlov during experiments on dogs at the end of the 19th century.

Minor salivary glands

They make up the bulk of all glandulae salivariae. They are located throughout the mouth.

Depending on the localization, the small glands are called:

buccal;
palatine;
lingual;
gingival;
molar (located at the base of the teeth);
labial.

According to the allocated secret, most of them are mixed, but there are serous and mucous membranes.

The main function is to maintain a normal level of saliva in the oral cavity. This does not allow the mucosa to dry out between meals.

Major salivary glands

The number of major salivary glands in humans is six. Among them are:

2 parotid;
2 submandibular;
2 sublingual.

Note. Glands are laid at the 2nd month of embryonic development from the epithelium of the oral mucosa and initially look like small bands. In the future, their size increases, future ducts appear. At the 3rd month, a canal appears inside these outflow tracts, connecting them to the oral cavity.

During the day, large glandulae salivariae synthesize an insignificant amount of saliva, however, when food is received, its amount increases sharply.

parotid gland

It is the largest of all salivary glands. It is serous in appearance. Weight about 20 grams. The volume of secretion released per day is about 300-500 ml.

This salivary gland is located behind the ear, mainly in the retromandibular fossa, in front limited by the angle of the lower jaw, behind - by the bone part of the ear canal. The front edge of the glandula parotidea (salivary gland) lies on the surface of the masseter muscle.

The body of the gland is covered with a capsule. The blood supply comes from the parotid artery, which is a branch of the temporal. Lymph outflow from this salivary gland goes to two groups of lymph nodes:

superficial;
deep.

The excretory duct (stenons) starts from the anterior edge of the glandula parotidea, then, having passed through the thickness of the masticatory muscle, it opens in the mouth. The number of outflow paths may vary.

Important! Since the body of the glandula parotidea is mostly in the bony fossa, it is well protected. However, it has two weaknesses: its deep part, adjacent to the internal fascia, and the posterior surface in the region of the membranous part of the auditory canal. These places with suppuration are the area of formation of the fistulous tract.

Submandibular salivary gland

There is also a large glandulae salivariae. It is somewhat smaller in size, and its weight is about 14-17 grams.

According to the type of secret produced by this gland, it is mixed.

Glandula submandibularis has an excretory duct called the Whartonian. It starts from its inner surface, going obliquely upward into the oral cavity.

sublingual salivary gland

It is the smallest of the major salivary glands. Its weight is only 4-6 grams. Oval in shape, may be slightly flattened. By type of secret mucous.

The excretory duct is called the Bartholin duct. There are options for its opening in the sublingual region:

independent opening, often near the frenulum of the tongue;
after confluence with the ducts of the submandibular glands on caruncula sublingualis;
many small ducts opening on the caruncula sublingualis (sublingual fold).

Diseases of the salivary glands

All diseases of glandulae salivariae are divided into several groups:

inflammatory (sialadenitis);
salivary stone disease (sialolithiasis);
oncological processes;
malformations;
cysts;
mechanical damage to the gland;
sialosis - the development of dystrophic processes in the tissues of the gland;
sialadenopathy.

The main symptom of the presence of glandulae salivariae disease is their increase in size.

The second symptom that characterizes the presence of problems with glandulae salivariae is xerostomia, or a feeling of dry mouth.

The third symptom of anxiety is pain. It may occur both in the region of the gland itself, and irradiation to the surrounding tissues.

Important! If you have at least one of the above symptoms, you should consult a doctor.

Examination of patients with suspected presence of certain disorders in the salivary gland begins with examination and palpation. Additional methods are probing (detects the presence of narrowing of the outflow tract), sialometry (measuring the rate of saliva secretion) with microscopy of the resulting secret.

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Treatment

Treatment of pathological processes in the area of the salivary glands is carried out depending on the etiology of the disease.

The most common of all diseases is sialadenitis. For the treatment of the inflammatory process, conservative etiotropic treatment is usually used. It consists in the appointment of antibiotics, antiviral, antifungal drugs. With the development of an extensive purulent process, the gland cavity is opened and drained.

Important! After surgical treatment, a scar remains on the skin in the access area (in the treatment of parotitis and sialosubmandibulitis). The salivary gland after the operation is completely restored after some time.

Also, a surgical method of treatment is resorted to when sialolithiasis occurs.

Oncological processes in the area of glandulae salivariae are treated by combined methods. More often, the surgical method (complete excision of the tumor and gland tissues) is combined with subsequent radiation or chemotherapy.

Conclusion

Salivary glands play an important role in human life. And it is very important to prevent the development of pathological processes in them. The easiest way to prevent is to maintain hygienic cleanliness of the oral cavity, the exclusion of smoking and alcohol. This will help maintain the full function of the glands for a long time.

parotid gland [glandula parotis(PNA, JNA, BNA)] is a salivary gland located in the parotid-masticatory region of the face. Oh. is the largest salivary gland (see Salivary glands).

For the first time O. was described in the middle of the 17th century. A large number of works have been devoted to the study of this organ.

Embryology

The lake, like other large salivary glands, develops from the epithelium of the oral cavity. The kidney of the gland appears in the embryo on the 6th week of development in the depth of the furrow separating the cheek from the gum, in the form of an epithelial cord, which grows towards the ear. On the 8th week embryonic development, the distal end of this strand begins to branch and gives rise to the excretory ducts and terminal secretory departments of O. zh. At the beginning of the 3rd month, gaps appear in the anlages of the excretory ducts, their epithelial lining becomes two-row, and in large excretory ducts it is multilayered. Differentiation of the glandular epithelium in the terminal secretory sections of O. zh. occurs somewhat later than in other salivary glands.

Anatomy

In O. distinguish between the superficial part (pars superficialis), adjacent to the masticatory muscle, and the deep part (pars profunda), which goes into the mandibular fossa (fossa retromandibularis). Sometimes the pharyngeal process departs from the inner edge of the gland. Oh. more often it is irregular pyramidal or trapezoidal, sometimes semilunar, triangular or oval (Fig. 1).

At the newborn O. has a mass of 1.8 g, contains a lot of loose connective tissue and blood vessels, its secretory function in the first 6 weeks. insignificant. Iron grows most intensively up to 2 years, increasing 5-6 times. At the end of the 2nd year of life, the gistol ends. O.'s differentiation., its growth is slowed down.

At the adult O.. weighs 20-30 g; its vertical size is 4-6.5 cm, sagittal 3-5 cm, horizontal 2-3.8 cm. In old age, the dimensions and weight of O. f. decrease.

Rice. 2. Scheme of the bed of the parotid gland (horizontal section): 1 - skin; 2 - subcutaneous tissue; 3 - superficial sheet of the fascia of the parotid gland; 4 - chewing muscle; 5 - lower jaw; 6 - medial pterygoid muscle; 7 - wall of the pharynx; 8 - deep leaf of the fascia of the parotid gland; 9 - styloid process; 10 - internal carotid artery; 11 - internal jugular vein; 12 - digastric muscle; 13 - sternocleidomastoid muscle.

Front O. Zh. adjacent to the chewing muscle (m. masseter), the branches of the lower jaw (g. mandibulae) and the medial pterygoid muscle (m. pterygoideus med.); behind it borders on the sternocleidomastoid muscle (m. sternocleidomastoideus), the posterior belly of the digastric muscle (venter post m. digastrici) and the mastoid process (processus mastoideus); medially adjacent to the styloid process (processus sty-loideus) and the awl-hyoid (m. stylohyoideus) and styl-lingual (m. styloglossus) muscles, the internal carotid artery (a. carotis int.) and the internal jugular vein (v. jugularis) extending from it int.), hypoglossal nerve (n. hypoglossus) and peripharyngeal tissue; from above it adjoins the zygomatic arch (areus zygomaticus) and the external auditory meatus (porus acusticus ext.). These formations limit O.'s bed. (fig. 2), a cut is lined with a fascia of O. zh. (fascia parotidea). Fascia O. fused with the fascia of the surrounding muscles and is attached to the edge of the lower jaw, zygomatic arch, mastoid and styloid processes. Between the angle of the lower jaw and the sternocleidomastoid muscle, the fascia forms a dense septum (Fig. 3), which separates O. Zh. from the submandibular gland (submandibular gland, T.; gl. submandibularis).

Through the thickness of O. large vessels and nerves pass; external carotid artery (a. carotis ext.) with the maxillary (a. maxillaris) and superficial temporal arteries (a. temporalis superficialis), v. retromandibularis, ear-temporal nerves (n. auriculotemporalis) and facial (n. facialis). The facial nerve (see) forms a parotid plexus (plexus parotideus) in the thickness of the gland, branches to-rogo, leaving the gland, diverge fan-shaped to the muscles of the face (Fig. 4). This determines the radial direction of the gland incisions during operations.

The system of excretory ducts of the gland is represented by intralobular, interlobular and interlobar ducts, to-rye merge into a common parotid duct (ductus parotideus), or stenon duct, which was first described by the Danish scientist N. Stenon in 1661. The length of the parotid duct 40-70 mm, its dia. 3-5 mm. The parotid duct usually comes from the upper third of the gland, goes around the edge of the chewing muscle and the fatty body of the cheek (corpus adiposum buccae) and opens on the eve of the mouth at the level of the upper second molar. In this place on the mucous membrane of the cheek there is a papilla O. Zh. (papilla parotidea). According to S. N. Kasatkin (1948), in 44% of cases the parotid duct is ascending, in 23% it is descending, less common is the straight, cranked, arcuate (Fig. 1), S-shaped and bifurcated parotid duct. In half of the cases, the duct of the accessory parotid gland (glandula parotis accessoria) flows into it. Sometimes a blind canaliculus leaves the parotid duct near its mouth, the so-called. Shievich's organ, a rudimentary salivary duct. The parotid duct contains valves and terminal siphons that regulate the excretion of saliva.

Blood supply is carried out by branches of the external carotid artery, superficial temporal artery, transverse artery of the face (a. transversa faciei), posterior and deep ear arteries (aa. auriculares post, et profunda). Intraorganic arteries and veins pass through interlobular septa. Venous outflow occurs in the pterygoid plexus (plexus pterygoideus) and the mandibular vein.

Lymphatic vessels O. Zh. flow into superficial and deep parotid limf, nodes (nodi lymphatici parotidei superficiales et profundi); their efferent vessels go to the superficial and deep cervical lymph nodes (nodi lymphatici cervicales superficiales et profundi).

Innervation is carried out by sympathetic and parasympathetic nerves. The preganglionic sympathetic fibers originate in the gray matter of the upper thoracic segments of the spinal cord and terminate in the superior cervical ganglion (gangl, cervicale sup.). Postganglionic sympathetic fibers go to O. Zh. as part of the external carotid plexus (plexus caroticus ext.). Sympathetic nerves constrict blood vessels and inhibit the secretion of saliva. It receives parasympathetic innervation from the lower salivary nucleus (nucleus salivatorius inf.) of the glossopharyngeal nerve (n. glossopharyngeus). Preganglionic fibers go as part of this nerve and its branches (n. tympanicus, n. petrosus minor) to the ear node (gangl, oticum). Postganglionic fibers reach the gland along the branches of the ear-temporal nerve. Parasympathetic fibers excite secretion and dilate blood vessels O. zh.

X-ray anatomy

O.'s cells. perform an excretory function, accumulating and removing various medicinal substances, poisons, toxins from the body with saliva, in patients with diabetes - sugar.

There are data testifying to the endocrine function of O. zh. Thus, biologically active substances (parotin, nerve growth factor, epithelial growth factor) were extracted from gland cells. Ito (I. Ito, I960) found that parotin has the properties of a hormone, affects protein and mineral metabolism. From O. isolated insulin-like protein. A histofunctional relationship was revealed O. Zh. with sex, parathyroid, thyroid, pancreas, pituitary and adrenal glands.

Research methods

At detection of pathology of O.. survey and survey of the patient, palpation of O. are of great importance, * to-rye allow to make the assumption of this or that disease of O.. (inflammation, swelling, damage, etc.).

An essential role in specification of the diagnosis is played by methods of laboratory, instrumental, X-ray radiol. research.

Probing of the parotid duct allows you to determine its patency and the presence of dense foreign bodies in it.

Cytol. a research of a secret of O., and also a puncture biopsy with gistol, a research of tissues of body help to reveal morfol, changes in gland, in particular in the presence of a tumor.

Secretory function O. Zh. investigate using sialometry (measurement of the amount of saliva released per unit of time), as well as radioisotope methods - radiosialography and radiosialometry, based on the ability of the O. parenchyma. concentrate and release radioactive isotopes 131 I, 99 Tc with saliva.

For definition of foreign bodys and morfol, changes in structure of channels and a parenchyma of O. zh. (hron, inflammation, tumor) produce x-rays of the gland without contrasting and with contrasting ducts (see Sialography).

Layered images of the organ are obtained using tomography (see), and the use of panoramic tomography (see Pantomography) makes it possible to simultaneously explore and compare the right and left O..

Ultrasonic dowsing (see. Ultrasound diagnostics ) is a method for diagnosing tumor processes in O.. and, in addition, allows you to judge the size of the gland and the degree of sclerosis of its parenchyma.

Scanning O. using 99 Tc (see Scanning) allows you to visualize the parenchyma of the gland, to identify the localization of its non-functioning areas, which is also an indirect sign of a violation of its function.

Diseases. Violation of the secretory function O. Zh. proceeds in the form of hyper- or hyposalivation.

Hypersalivation occurs as a result of direct or reflex stimulation of the salivary center or secretory nerves of the gland. It is observed with bulbar paralysis, inflammatory processes in the oral cavity and stomach, diseases of the esophagus (esophagosalvation reflex), nausea and vomiting, helminthic invasions, toxicosis of pregnancy, under the action of certain drugs that affect the autonomic nervous system (pilocarpine, physostigmine), etc. In certain poisonings, hypersalivation is a protective reaction of the body - toxic metabolic products, poisons, etc. are excreted with saliva. Prolonged hypersalivation leads to disruption of the stomach and intestines, metabolism, and depletion of the body. With hypersalivation, the underlying disease is treated.

Foreign bodies. In some cases, foreign bodies (eg, bristles from a toothbrush, husks from seeds, etc.) penetrate from the oral cavity into the parotid duct and cause stagnation of saliva (see Sialostasis), which is accompanied by an increase in O. zh. and the appearance of shooting pains in the parotid-chewing region. Sometimes an infection joins and acute inflammation of the parotid duct occurs (see Sialadenitis), followed by suppuration of the O. tissue. Foreign bodies are removed surgically.

stones. In O. and parotid duct stones are rare. The clinical picture depends on the localization of the stone and the stage of chronic inflammation (see Sialolithiasis).

cysts. In O. mainly retention cysts are found, to-rye occur with long-term obstacles to the outflow of saliva (infection of the parotid duct after injury or inflammation, compression of the parotid duct by a growing tumor, etc.). Except retention cysts, in O. zh. occasionally observed cysts arising on the basis of malformations. Treatment of cysts is operative.

Tumors parotid gland, as well as other salivary glands, differ in variety and complexity gistol, structures, variability a wedge, a current.

benign tumors. Most often in O.. polymorphic adenomas, or mixed tumors are observed (see). To rare tumors O. Zh. include adenolymphoma (see), oxyphilic adenoma, or oncocytoma (see Adenoma), acinar cell tumor, hemangioma (see), fibroma (see Fibroma, fibromatosis), neurinoma (see).

Benign tumors are usually localized in the thickness of O. zh. and on examination are determined in front of the auricle or in the fossa retromandibularis (Fig. 6). Tumors of a pharyngeal shoot O. zh. bulge and deform the wall of the pharynx, causing awkwardness or difficulty in swallowing. The degree of deformation of the pharyngeal wall depends on the size of the tumor. Benign tumors have a densely elastic consistency, a smooth or bumpy surface, and are painless. The facial nerve, as a rule, is not involved in the tumor process, the skin over the tumor is not changed.

Acinar cell tumor refers to locally destructive neoplasms, has infiltrative growth, does not metastasize, is observed only in women.

Treatment of benign tumors is surgical. The type of surgery for mixed and acinar cell tumors depends on the size and location of the neoplasm. If the mixed tumor has a size of up to 2 cm, is located in the edge of the gland, then marginal resection of the O. is performed. The indication to a subtotal resection O. zh. in the plane of location of the branches of the facial nerve are mixed tumors of considerable size, localized in the superficial part of the gland, as well as neoolyny acinar cell tumors.

Parotidectomy (removal of the O. g.) with the preservation of the facial nerve and its branches is carried out in the presence of large tumors, their localization in the pharyngeal process and the multiplicity of tumor nodes. The operation is recommended to be performed under anesthesia. The skin incision in most cases starts from the scalp of the temporal region, is carried out in the immediate vicinity of the auricle in front of it, and bending around the earlobe from front to back, the incision is made vertically 4-5 cm below the angle of the lower jaw. If necessary, the incision can be extended down to remove regional limf, nodes on the neck. With a large tumor, it is recommended to make an additional horizontal incision parallel to the base of the body of the lower jaw, stepping down by 2-3 cm. Parotidectomy is started from the side of the main trunk of the facial nerve (Fig. 7), less often from its peripheral branches. First, the superficial part of O. is removed, and then the deep part is isolated, while the external carotid artery is ligated and v. retromandibularis. The wound is sutured in layers. For other benign tumors, the neoplasm is enucleated without damaging the capsule. Vascular tumors decrease in size under the influence of radiation therapy, so they can be subjected to preoperative radiation.

The forecast at high-quality tumors O. zh. favorable in most cases.

Malignant tumors Oh. are observed, as a rule, at the age of over 40 years. They are characterized by pain in the region of the gland, infiltration of the skin over the tumor, frequent lesions of the facial nerve, metastasis to regional limf, nodes of the parotid region of the face and neck.

Mucoepidermoid tumors (see) occur predominantly in women. These tumors are characterized by soreness, dense texture, non-displacement of the tumor, infiltration and swelling of the skin. They have infiltrative growth, frequent lymphogenous metastasis.

Distinguish several gistol, forms of cancer O. Zh.: cystadenoid carcinoma, adenocarcinoma, squamous cell carcinoma, undifferentiated cancer, cancer from a mixed tumor.

Cystadenoid carcinoma (cylindroma) in O. Zh. is rare. The tumor has a dense texture, a smooth or bumpy surface, lacks clear boundaries, and is almost always painful. The cystadenoid carcinoma in limf, nodes metastasizes seldom.

Adenocarcinoma is somewhat more common in men. The tumor may have clear boundaries or diffusely infiltrate surrounding tissues.

Squamous cell carcinoma O. Zh. rare, predominantly in men. The variant of squamous nonkeratinized cancer prevails. The wedge, the current differs in high degree of a zlokachestvennost.

Undifferentiated cancer O. Zh. slightly more common in women. The tumor has a dense texture, fuzzy borders. As neoplasms grow in the O. area. pain occurs, the skin over the tumor is infiltrated, symptoms of damage to the facial nerve appear. Frequent relapses of the tumor, regional and distant metastases to the lungs and bones; the growth of metastases may outpace the growth of the primary tumor.

Cancer from a mixed tumor (malignant polymorphic adenoma) is rare, predominantly in women; its feature is a pronounced cellular polymorphism of the malignant component of the tumor. The tumor, as a rule, has the form of a clearly delimited dense node, sometimes partially covered with a capsule. Long-existing tumors reach large sizes, grow into the external auditory canal, lower jaw, and into the bones of the base of the skull. Metastases in limf, nodes are observed less often than hematogenous metastases.

Sarcoma (see), lymphoreticular tumor, malignant neuroma (see) O. Zh. morphologically and on character a wedge, currents are similar to similar tumors of other localization.

In O. metastases of malignant tumors of other organs may occur.

Diagnosis of tumors O. Zh. it is difficult and is based on a wedge, data, results tsitol, and rentgenol, researches. X-ray. examination of the skull and sialography make it possible to judge the prevalence of the tumor process.

Treatment of malignant tumors O. Zh. carry out taking into account the prevalence of the tumor process and gistol, the structure of the neoplasm. Well and moderately differentiated mucoepidermoid tumors are removed surgically: parotidectomy is performed with preservation of the branches of the facial nerve. Poorly differentiated mucoepidermoid tumors, as well as cystadenoid carcinoma and other types of O. cancer. are subject to the combined treatment, a cut includes preoperative (for 3-4 weeks prior to operation) remote gamma therapy on the area of primary center in a total dose of 5000-7000 I am glad (50-70 Gy) and the subsequent surgical intervention. At cancer O. shows a complete parotidectomy (without preserving the facial nerve) with fascial-case excision of the tissue of the neck. In the presence of multiple and poorly displaced regional metastases, a complete parotidectomy is combined with the Crile operation (see Crile operation). For the treatment of patients with advanced forms of malignant tumors O. Zh. radiation therapy may be used.

The five-year survival rate for malignant neoplasms is 20-25%.

Bibliography: Vasiliev G. A. Plastic restoration of the stenon duct, Dentistry, No. 3, p. 39, 1953; Kalinin V. I. and Nevoro-t and A. I N. Ultrastructure of acinar cells of human parotid salivary glands, ibid., t. 55, No. 3, p. 16, 1976; Kosatkin S. N. Anatomy of the salivary glands, Stalingrad, 1949; Klementov A. V. Diseases of the salivary glands, D., 1975; The experience of Soviet medicine in the Great Patriotic War of 1941-1945, vol. 6, p. 240, M., 1951; Pani k a r o v with k and y VV Tumors of the salivary glands, Guide to the pathologist. diagnosis of human tumors, ed. N. A. Kraevsky and A. V. Smolyannikov, p. 127, M., 1971; Paches A. I. Tumors of the head and neck, p. 222, M., 1971; With about lntsev A. M. and Koles about in V. S. Surgery of the salivary glands, p. 70, Kyiv, 1979; Electron microscopic anatomy, ed. S. Kurtz, trans. from English, p. 60, M., 1967; Conley J. Salivary glands and facial nerve, Stuttgart, 1975; ("only G., Guilbert F. et Descrozailles JM Anatomie fonctio-nelle et siphons terminaux du canal de Ste-non, Rev. Stomat. (Paris), t. 77, p. 645, 1976; Evans RW a. C rui c k-shank A. Epithelial tumours of the salivary glands, Philadelphia, 1970; K it amura T. Atlas of diseases of the salivary glands, Tokyo, 1972; Rauch S. Die Speicheldriisen des Menschen, Stuttgart, 1959; Schulz H G. Das Rontgen-bild der Kopfspeicheldriisen, Lpz., 1969; Thackray A. C. Histological typing of salivary gland tumours, Geneva, WHO, 1972.

I. F. Romachev; O. M. Maksimova, A. I. Paches (onc.), V. S. Speransky (an., gist., embr.).

1951 0

Most of the gland is located on the outer surface of the mandibular branch, the smaller one is in the retromandibular fossa formed by the mandibular branch, the internal pterygoid muscle, the mastoid process, the sternocleidomastoid muscle, the posterior belly of the digastric muscle, and the lower wall of the external auditory canal. The shape of the gland is very diverse, but many authors find that it is similar to a trihedral pyramid, although in reality the outlines of the parotid salivaryglands (SJ) hard to compare with anything.

The gland has three surfaces: external, anterior, posterior, and two bases or, in the words of many authors, "two poles". The front edge of the gland somewhat covers the outer surface, the rear edge - the sternocleidomastoid muscle; the lower pole often reaches the angle of the lower jaw, and the upper pole sometimes reaches the zygomatic arch.

Rice. 1.4. Schematic representation of the location of the superficial and deep sheets of the parotid-masticatory fascia: 1 - parotid SG; 2 - superficial and deep leaves of the parotid-masticatory fascia; 3 - chewing muscle; 4 - lower jaw; 5 - peripharyngeal fiber; 6 - sternocleidomastoid muscle

The gland is enclosed in a case formed by the parotid-masticatory fascia, which is a superficial sheet of the facial fascia itself (Fig. 1.4). This case, together with the chewing muscle, is attached at the top to the zygomatic bones and the zygomatic arch, at the bottom - to the outer surface of the angle of the lower jaw. At the posterior edge of the chewing muscle, the chewing fascia splits and covers a portion of the parotid gland located on the outer surface of this muscle.

Front own fascia of the parotid gland- this is a dense sheet, from which the processes penetrate into the thickness of the gland and divide it into lobules. In the course of the parotid duct, the fascia thickens and contains accompanying vessels and, sometimes, an additional lobule of the gland.

Rice. 1.5. Fascia and cellular spaces according to E. Singer: 1 - fascial bed of the parotid salivary gland; 2 - fascial capsule of the submandibular salivary gland; 3,4 - case of the sternocleidomastoid muscle; 5 - lower jaw; 6 - parotid-chewing, or own, fascia of the face; 7.9 - superficial fascia of the head (tendon helmet); 8 - three leaves of the temporal aponeurosis

The bed of the gland is a space that limits the leaves of the parotid-chewing fascia (Fig. 1.5). In the formation of the inner leaf of the fascia of the gland, the cases of the sternocleidomastoid and digastric muscles (posterior abdomen), the cases of the muscles coming from the styloid process are involved; in front - the fascial case of the internal pterygoid muscle, below and inside - the cases of the stylohyoid and digastric muscles (anterior belly). The upper surface of the gland, facing the external auditory canal, and the inner surface of the pharyngeal process of the gland are not covered with fascia and are separated by loose tissue. The spur enters the gap between the auditory canal and the capsule of the temporomandibular joint.

In the region of the pharyngeal process, in the lower part, where the inner surface of the parotid gland faces the posterior belly of the digastric and stylohyoid muscles, there is also a strong fascia. A part of the inner surface of the gland without a fascial cover is adjacent to the tissue of the peripharyngeal space (Fig. 1.6). The parotid-masticatory fascia passes into the fascial formations of neighboring structures (outside - into the superficial fascia of the neck, behind - into the prevertebral fascia, inside - into the stylo-pharyngeal aponeurosis and vascular sheath). The thickness of the capsule of the parotid gland depends on the age and sex of the person.

Rice. 1.6. Schematic representation of the relationship between the inner surface of the gland and the peripharyngeal space: 1 - parotid salivary gland; 2 - peripharyngeal space; 3 - the posterior belly of the digastric muscle and the stylohyoid muscle; 4 - sternocleidomastoid muscle; 5 - internal carotid artery and internal jugular vein; 6 - wall of the pharynx; 7 - palatine tonsil

The skin above the parotid SF is well displaced, under it there is a thin layer of subcutaneous fatty tissue surrounding the outer sheet of the fascia of the gland and passing into the tissue of neighboring areas, which leads to the unhindered spread of the tumor infiltrate in all directions. A deep sheet of the parotid-masticatory fascia separates the gland from the lateral wall of the pharynx, the posterior belly of the digastric muscle, from the muscles and ligaments attached to the styloid process, from the posterior surface of the internal pterygoid muscle.

At the posterior edge of the gland, the inner sheet of the fascia merges with the outer one, and at the angle of the lower jaw, both sheets form a strong septum separating the lower pole of the parotid SF from the submandibular salivary gland.

The fascial cases of vessels and nerves are fused with the capsule of the gland, therefore, no defects are left in the capsule at the points of their entry or exit. However, the possibility of spreading the pathological process is described along the external carotid artery to the region of the carotid triangle of the neck, and along the internal maxillary artery - to the maxillary pterygoid fissure of the masticatory space.

At the anterior edge of the parotid SF, above the parotid duct, sometimes there is an additional lobe of the parotid gland measuring 1-2 cm in diameter. It occurs in 10-20% of individuals and can be a source of tumor development.

Rice. 1.7. Vessels and nerves of the head, passing in the bed of the parotid salivary gland: 1 - external carotid artery; 2 - posterior ear artery; 3 - superficial temporal artery; 4 - transverse facial artery; 5 - projection of the internal maxillary artery; 6 - retromandibular vein; 7 - large ear nerve

The parotid SF secretes its secretion from the parotid salivary duct. Usually it is main and receives side channels (from 7 to 18) on its way. In some cases, it is formed from the confluence of two ducts almost equal in diameter, sometimes it has a branching structure. The parotid duct exits at the border of the upper and middle thirds of the parotid SF and goes obliquely upwards and forwards, and then, turning downwards, goes horizontally along the outer surface of the masticatory muscle. At its edge, the duct bends inward, penetrates the oblique fatty tissue and the buccal muscle.

Rice. 1.8. Branches of the facial nerve (from the Sobotta atlas): 1 - temporal branch; 2 - mandibular branch; 3 - buccal branch; 4 - zygomatic branch; 5 - cervical branch

Then, for 5 cm, the duct is located along the buccal mucosa and opens in front of the mouth at the level of the upper second molar or between the first and second upper molars. The opening of the parotid duct has a rounded shape or the shape of a narrow slit, often located on a hill in the form of a papilla. The diameter of the duct is 3 mm, its length is from 15 to 40 mm. The duct of the accessory lobe of the gland flows into the parotid duct, which gives rise to many researchers not to call it an independent gland. Often the front edge of the parotid gland protrudes far forward and almost reaches the front edge of the masticatory muscle. In such cases, the beginning of the parotid duct is masked by the gland.

Most anatomists and surgeons determine the projection of the parotid duct along the line connecting the tragus of the auricle and the corner of the mouth. In children, the duct is often projected along the line: the corner of the mouth and the lobe of the auricle.

In the bed of the parotid salivary gland, numerous blood and lymphatic vessels, nerves and lymph nodes pass (Fig. 1.7 and 1.8). In most cases, the vessels are located in the thickness of the gland, closer to its anterior surface. Sometimes the vessels pass along the inner surface of the gland. The largest blood vessel is the external carotid artery, which is tightly fused with the parenchyma of the gland and here is divided into its terminal branches: the posterior auricular, superficial temporal, transverse facial and maxillary. Outside of the external carotid artery is the external jugular vein. The posterior ear and transverse facial veins flow into it. Venous blood flows through the posterior mandibular vein, which is formed from the confluence of the superficial temporal and maxillary veins.

Rice. 1.9. Schematic representation of four variants of division of the facial nerve according to Vaccato:a - classic type; b - ladder type; c - anastomosing type; g - anastomosing type with a short loop

The parotid SF is innervated by the parotid branches of the ear-temporal nerve; secretory fibers - from the ear ganglion; sympathetic nerves accompany the superficial temporal artery. The accessory lobe of the parotid SF and the parotid duct are innervated by branches of the facial nerve.

Through the parotid salivary gland passes the extracranial part of the facial nerve, which is the VII pair of cranial nerves. The facial nerve exits the skull through the stylomastoid foramen. The length of the nerve to the posterior edge of the parotid SF is on average 10 mm. During surgery, as noted by some surgeons, it is possible to lengthen this segment of the nerve by pulling the lower jaw forward. The facial nerve penetrates into the parotid SF more often in the middle third of the gland. In the parenchyma of the gland, the nerve runs along a common trunk of about 15 mm, always outward from the external carotid artery and external jugular vein. The facial nerve then divides into two branches.

Rice. 1.10. Schematic representation of six variants of the structure of the facial nerve according to Devis et al. (as a percentage): 1 - temporal branch; 2 - zygomatic branch; 3 - buccal branch; 4 - marginal mandibular branch; 5 - cervical branch

One branch goes horizontally, continuing the course of the common trunk, and is divided into three branches. The other branch goes downward almost at a right angle, passes the greatest distance in the parenchyma of the gland (about 20 mm) and is also divided into two branches. Very rarely, the facial nerve divides before entering the parotid salivary gland. In the gland itself, the nerves anastomose widely with each other, which creates significant difficulties in isolating them during surgery. Five main branches of the facial nerve emerge from the gland tissue to the mimic muscles of the face: temporal, zygomatic, buccal, mandibular marginal, cervical.

According to the general opinion of researchers, the topography of the five main branches of the facial nerve is extremely variable. Various options for the division of the facial nerve are described (Fig. 1.9, 1.10 and 1.11). As a guide in practical surgery, the position of the parotid duct can be used to find the mandibular branch heading to the corner of the mouth, and a straight line connecting the corner of the eye with the earlobe can be used to find the zygomatic branch.
The auricular-temporal nerve, which is a branch of the mandibular nerve, also passes through the parotid SF.

Rice. 1.11. Schematic representation of eight variants of the structure of the facial nerve according to Mac Cormak (as a percentage): T - temporal branch; Z - zygomatic branch; B - buccal branch; M - mandibular branch; C - cervical branch

The ear-temporal nerve penetrates into the gland somewhat below and behind the articular process of the lower jaw and breaks up into many small trunks, the topography of which is complex. One of the branches accompanies the superficial temporal artery, the other branches form a thickening in the form of a plate, from which numerous thinnest branches depart in different directions (including to the skin of the auricle and external auditory canal), which anastomose with the sympathetic plexus of the external carotid artery.

The parotid SF is divided into superficial and deep parts. The superficial part corresponds to that part of the gland, which is located on the masticatory muscle. The deep part occupies a recess behind the branch of the lower jaw. The facial nerve and its connective tissue case, passing through the thickness of the gland, are a landmark, outside of which the superficial part is located, from the inside - deep. Our extensive surgical experience indicates that finding the plane of location of the branches of the facial nerve allows us to technically correctly perform various volumes of resections and complete removal of the parotid salivary gland while preserving the facial nerve.

A. I. Paches, T. D. Tabolinovskaya

Chapter 2

Methods for examining patients with diseases of the salivary glands require special skills that are within the competence of a dentist. The doctor should be able to examine the oral cavity, know the topography of the salivary glands, find the mouths of their ducts.

In the monograph by I.F. Romacheva (1973) identified three groups of methods for examining the salivary glands: general, private and special.

The general methods include methods used to examine patients with any pathology: questioning, examination, palpation, blood tests, urine tests.

Particular methods can be used to examine patients with certain pathologies, for example, diseases of the salivary glands, the cardiovascular system, the gastrointestinal tract, etc.

Special examination methods are carried out by qualified specialists using special equipment.

2.1. General methods of examination of the salivary glands

Major salivary glands - these are internal organs, the examination of which must be guided by the principles and rules adopted in the clinic of internal diseases.

The following diseases can develop in the salivary glands:

Reactive-dystrophic (sialadenoses);

Acute inflammation of the salivary glands (acute viral sialadenitis, acute bacterial sialadenitis);

Chronic inflammation of the salivary glands (interstitial, parenchymal, ductal siala de-nites);

Specific damage to the salivary glands (actinomycosis, tuberculosis, syphilis);

Salivary stone disease;

salivary gland cysts;

Tumors of the salivary glands;

Salivary gland damage.

Considering the variety of pathologies, during the survey they find out whether pain and swelling in the area of the salivary glands are disturbing, whether these symptoms are associated with eating, hypothermia, stress, whether there is dryness of the mouth, eyes, and the presence of a salty taste in the mouth. It is necessary to trace the chronology of the disease: when the symptoms of the disease first appeared, how often and how exacerbations occur, when was the last exacerbation, what treatment was carried out. The complexity of differential diagnosis lies in the fact that the same symptom can be present in different diseases. For example, in acute sialadenitis, as well as in exacerbation of a chronic one, a painful enlargement of one or more large salivary glands can be determined. Painless symmetrical enlargement of the parotid salivary glands is present with:

sialadenosis;

Late stage of chronic sialadenitis in remission;

Autoimmune diseases: Sjögren's disease and syndrome;

Granulomatous diseases: Wegener's granulomatosis and sarcoidosis;

Congenital polycystosis;

After intravenous administration of radioactive iodine 131 I;

MALT-lymphoma;

papillary lymphomatous cystadenoma (Warthin tumor);

Mikulich's diseases;

Stages of primary manifestations of HIV infection (AIDS).

During examination (Fig. 3) and palpation (Fig. 4), the size, texture, surface (smooth, bumpy), mobility, soreness of the salivary glands, and the color of the skin over them are assessed. Assess color and moisture

Rice. 3. Appearance of a patient with bilateral parenchymal parotitis

Rice. 4. Palpation of the parotid salivary glands

Rice. five. Examination of the vestibule of the oral cavity. On the mucous membrane of the lower lip on the right is a retention cyst of the small salivary

glands

Rice. 6. Bimanual palpation of the submandibular salivary gland

mucous membrane of the oral cavity (Fig. 5), the mouth of the excretory ducts, the amount, color, consistency of the excreted secret, the presence of free saliva, bimanual palpation of the salivary glands and ducts is performed (Fig. 6).

An additional examination is necessary to make a definitive diagnosis.

2.2. Private methods of examination of the salivary glands

There are the following private methods for examining the salivary glands:

Probing the excretory ducts of the salivary glands;

Plain radiography of the salivary glands;

Sialometry;

Sialography;

Pantomosialography;

Cytological examination of the secret;

Qualitative analysis of saliva.

These methods are called private because they are used when examining only one specific organ or organs, in this case, the large salivary glands.

sounding carried out with special salivary probes. This method allows you to determine the direction of the duct, the presence of a narrowing, a calculus in the salivary duct (Fig. 7). Probes must be handled carefully, without much effort, since the wall of the duct is thin, does not have a muscular layer and can be easily perforated.

Rice. 7. Probing the duct of the parotid salivary gland

Plain radiography of the salivary glands(Fig. 8) is used to determine radiopaque calculi in the submandibular and parotid salivary glands. On the radiograph, a shadow is determined in the projection of the salivary stone.

For examination of the submandibular salivary gland, a mandatory x-ray examination is necessary in two projections: lateral - to determine the stone in the intraglandular ducts and the floor of the oral cavity in the area of the Wharton duct if a stone is suspected in the excretory duct and near the mouth. You can use styling according to V.S. Kovalenko.

When examining the parotid salivary gland, an X-ray examination is usually performed in a direct projection, sometimes - soft tissues of the buccal region (with the location of the calculus in the area of the mouth of the Stenon duct).

Rice. 8. Plain radiography: a - submandibular salivary gland in lateral projection; b - floor of the mouth; c - parotid salivary gland in direct projection

When reading an orthopantomogram, shadows of calculi can also sometimes be detected, especially if they are present in several salivary glands.

Not all salivary gland stones are radiopaque, it depends on the degree of mineralization of the stones, in this case, other methods must be used to confirm the diagnosis.

Sialometry- a quantitative method that allows you to evaluate the secretory function of the salivary glands per unit of time. There are many techniques for quantifying both mixed saliva and ductal secretions from individual major salivary glands. It is possible to estimate the amount of secreted unstimulated and stimulated saliva. To stimulate salivation, chewing paraffin, applying a 2% solution of citric acid * or a 5% solution of ascorbic acid to the tongue, and ingesting 8 drops of a 1% solution of pilocarpine before the study are used.

Saliva collection is carried out in the morning on an empty stomach. The patient is given recommendations: before the examination, do not brush your teeth, do not rinse your mouth, do not smoke, do not chew gum.

The Commission on Dental Health, Research and Epidemiology (CORE) of the International Dental Federation (FDI, 1991) recommends collection of mixed saliva by self-flow from the mouth or by spitting into a measuring container within 6 minutes. The salivation rate, expressed in ml/min, is calculated by dividing the total volume of saliva collected by six. The rate of release of mixed saliva without stimulation averages from 0.3 to 0.4 ml / min, stimulation increases this figure to 1-2 ml / min. However, it must be remembered that these indicators are very variable and individual. The symptom of dryness in the oral cavity appears when the salivation rate decreases to 50% of the initial individual level.

To assess the average age norm for the amount of mixed saliva secreted per unit of time, M.M. Pozharitskaya recommends determining by the formula:

for men:

[-0.09 (x - 25) + 5.71];

for women:

[-0.06 (x - 25) + 4.22], where X- age in years.

Collection of saliva from individual salivary glands is carried out using special cannulas according to the method of T.B. Andreeva (Fig. 9) or Lashley-Yushchenko-Krasnogorsky capsule (Fig. 10).

Rice. nine. Sialometry according to T.B. Andreeva using a metal cannula

Rice. 10. Lashley-Yushchenko-Krasnogorsky capsule: a - capsule; b - method of using the capsule

Sialometry according to the method of T.B. Andreeva

After ingestion of 8 drops of a 1% solution of pilocarpine, 20 minutes after preliminary bougienage, special cannulas are inserted into the duct (ducts) of the parotid or submandibular salivary glands. The collection time of saliva is 20 minutes after the appearance of the first drop of secretion. For the parotid salivary gland, the norm for the amount of secretion is 1-3 ml, for the submandibular gland - 1-4 ml.

The Leshli-Yushchenko-Krasnogorsky capsule consists of two chambers. The outer chamber is used for suction

to the mucous membrane. The secret of the parotid salivary gland is collected in the inner chamber and sent to a graduated test tube. As a salivary stimulator, a 3% solution of ascorbic acid is used, which is periodically (every 30 s) applied to the dorsal surface of the tongue. The ductal secretion is collected within 5 minutes from the moment the first drop appears in the tube (Fig. 11). The amount of secretion obtained and the presence of an inflammatory sediment in the form of strands and lumps of mucus are estimated. A decrease in secretion of the 1st degree is determined if the amount of secreted saliva is 2.4-2.0 ml, of the 2nd degree - 1.9-0.9 ml, of the 3rd degree - 0.8-0 ml. The disadvantage of this method is the impossibility of conducting sialometry from the submandibular salivary glands, and the advantage is a wider lumen of the tube, which makes it possible to obtain objective data even with an increased viscosity of the secretion and the presence of mucous inclusions in it.

There is a technique that allows you to assess the overall secretory capacity of the salivary glands by resorption of a standard 5-gram piece of refined sugar. In healthy people, this time averages 52 ± 2 s and should not exceed 103 s.

The secretion of the minor salivary glands is quantified using filter paper strips, which are weighed before and after the study.

The functional state of the minor salivary glands can be assessed by counting discolored dots on a 2x2 cm area of the mucous membrane of the lower lip, stained with methylene blue. Normally, 21 ± 1 function.

For cytological examination of the secret(Fig. 12) it is taken using a Volkmann spoon or a special cannula (middle portion). A drop of the secret is placed on a glass slide, a smear is made and stained according to Romanovsky-Giemsa. The drug is examined under a microscope.

Normally, in the secretion of the large salivary glands, single cells of squamous and cylindrical epithelium are found, lining the excretory ducts of the glands, sometimes neutrophilic leukocytes and lymphocytes. With age, an increase in the number of epithelial cells in the secret is noted.

Rice. eleven. Sialometry using Lashley-Yushchenko-Krasnogorsky capsule

The presented method plays an important role in the diagnosis of acute and chronic sialadenitis, reactive-dystrophic diseases of the salivary glands, salivary stone disease and tumor processes in the area

glands.

Sialography- This is an x-ray of the salivary glands using artificial contrast. In ca-

Rice. 12. Cytograms of the ductal secretion of the parotid salivary gland

As a contrast, water-soluble substances are used - sodium amidotrizoate (urographin ♠), iohexol (omni-pack ♠) and fat-soluble substances (iodolipol ♠, lipiodol ultra-fluid ♠). Currently, iohexol (omni-pak-350, iodine content 35%) is most often used for contrasting the salivary glands. The introduction of the drug is carried out in the X-ray room. Before the procedure, the salivary gland duct is bougied (Fig. 13). Enter into the duct

Rice. 13. Introduction of a contrast agent omnipak-350 into the duct of the right parotid salivary gland

0.5-2.0 ml of the solution until a subjective sensation of light bursting and pain in the gland under study. To introduce a substance into the gland, metal cannulas (injection needles with a blunt end) are used.

When examining the parotid salivary gland, X-ray images are taken in frontal and lateral projections, and the submandibular salivary gland - in lateral projection. Sialography should not be performed during the acute period of the disease.

On the sialogram (Fig. 14), one can determine the shape and size of the gland, the uniformity of the filling of the parenchyma. Normally, ducts of the I-V orders should be visible, having even, clear contours. In chronic sialadenitis, the ducts may have uniform

and uneven areas of contraction and expansion, be indistinct and discontinuous. With parenchymal parotitis, cavities of various diameters filled with a contrast agent are determined on the sialogram. With salivary stone disease, a defect in filling the duct of the gland is possible.

This method remains the most accessible and informative in the diagnosis of various forms of chronic sialadenitis.

Rice. fourteen. Sialographic picture of a normal salivary gland: a - submandibular; b - parotid

Pantomosialography(Fig. 15) is a method of simultaneous radiopaque examination of two or more large salivary glands, followed by panoramic tomography. The image of all contrasted salivary glands obtained in one picture makes it possible to conduct a comparative analysis of paired salivary glands.

Qualitative analysis of the secret. When taking saliva, pay attention to its color, transparency, visible inclusions.

Saliva is 99% water, 1% is represented by proteins, electrolytes and low molecular weight substances. There are many methods that allow you to determine all the known ingredients of saliva. Recently, saliva analysis is often used as a non-invasive method for monitoring the level of hormones, medications and substances that are prohibited for consumption. A clear correlation was noted in the levels of a number of hormones and drugs between blood plasma and saliva. to those transported through

Rice. 15. Pantomosialograms (Morozov A.N.)

hematosalivary barrier substances include most electrolytes, albumin, immunoglobulins G, A, and M, vitamins, drugs, hormones, and water. Saliva is currently being tested in screening for the presence of antibodies to the human immunodeficiency virus (HIV).

Qualitative analysis of individual components of saliva has an advantage over blood tests. Saliva sampling can be carried out repeatedly, as the patient does not experience stress. The possibilities of examining children are expanding.

Microbiological method for the study of saliva. The ducts of the salivary glands and saliva are one of the least studied biotopes of the oral cavity. Some researchers argue that due to the high bactericidal activity of enzymes, lysozyme, secretory immunoglobulins and other factors of specific and nonspecific protection, saliva in the ducts of the glands of a healthy person should be practically sterile. Others allow the presence of a small amount of bacteria belonging mainly to obligate anaerobic species (Veillonella, Peptostreptococcus). In addition, there are difficulties with the collection of material and the exclusion of contamination of samples by the microflora of the mucous membrane and oral fluid. For sterile examination of saliva, various cannulas are used, which are inserted into the excretory duct of the salivary gland. Next, perform sowing on nutrient media for anaerobic cultivation.

2.3. Special methods of examination of the salivary glands

Special methods for examining the salivary glands include:

Sialosonography;

Computed tomography of the salivary glands;

Functional digital subtraction sialography;

MRI of the salivary glands;

Morphological research methods: diagnostic puncture, biopsy of minor salivary glands, biopsy of major salivary glands;

Radiosialography (dynamic scintigraphy).

Sialosonography (ultrasound examination of tissues)(Fig. 16). The basis of the method is a different degree of absorption and reflection of the ultrasonic signal, depending on the density of the tissues. When examining the gland, it is possible to determine: size, shape, contour, ratio with adjacent anatomical formations, echogenicity of the parenchyma of the gland, its structure, it is also possible to visualize hyperechoic and hypoechoic areas, calculi, lymph nodes. This method has found wide application due to its availability, non-invasiveness, the possibility of frequent re-examination without side effects, and high reliability. Ultrasound of the salivary glands is used to diagnose tumors, acute and chronic inflammatory diseases of the salivary glands, reactive-dystrophic diseases, salivary stone disease.

Computed tomography of the salivary glands(Fig. 17) is a method of layer-by-layer tissue scanning, which is used to study structural changes in the large salivary glands. Computed tomography is most often used to examine the glands in case of suspicion of volumetric formations. To study the ductal system

Rice. 16. Sialosonography. Normal image of the salivary glands (Yudin L.A., Kondrashin S.A.): a - parotid; b - submandibular

Rice. 17. Computed tomogram (Yudin L.A., Kondrashin S.A.)

In the salivary glands, there is a way to pre-inject a contrast agent into the ducts of the gland before scanning. Computed tomography data for salivary stone disease allow you to accurately determine the size and location of the calculus. The method is uninformative in the differential diagnosis of various forms of chronic sialadenitis.

Functional digital subtraction sialography(Fig. 18) serves to assess the morphofunctional state of the salivary glands. There are three main phases of subtraction sialography:

Contrasting of the main excretory and intraglandular ducts;

Contrasting of the parenchyma of the gland;

Evacuation of the contrast agent from the parenchyma and ducts of the gland.

The study time of unaffected salivary glands is 40-50 s.

This digital method has a number of advantages over traditional analog sialography, allowing:

To study the sialographic picture in isolation due to the effect of subtraction (there is no imposition of the image of the salivary gland on the underlying bone structures - the vertebral bodies, the jaw branch);

Objectively control the amount of injected contrast agent, and not focus only on subjective sensations of fullness and the appearance of pain;

To study not only the structural features of the salivary glands, but also functional parameters, in particular,

Rice. eighteen. Functional digital subtraction sialography: a - contrasting phase of the main excretory and intraglandular ducts; b - phase of contrasting the parenchyma of the gland; c - the phase of evacuation of the contrast agent from the parenchyma and ducts of the gland. The time of examination of unaffected salivary glands is 40-50 s (Yudin L.A., Kondrashin S.A.)

the rate of evacuation of the contrast agent from the excretory ducts.

Magnetic resonance imaging of the salivary glands -

This is a method of studying tissues, in which the image is formed due to the interaction of the magnetic moments of the hydrogen nuclei located in the substance of the object under study, and magnetic fields. MRI is indicated in difficult diagnostic cases. This method is used to diagnose neoplasms, chronic inflammatory and reactive-dystrophic diseases of the salivary glands.

It allows you to clarify the nature of the disease of the large salivary glands and at the same time diagnose the lesion in the glands, where the process proceeds without clinical manifestations.

Morphological research methods: diagnostic puncture, biopsy of minor salivary glands, biopsy of major salivary glands.

Diagnostic puncture carried out with a 10 ml syringe. After processing the surgical field, a neoplasm puncture is performed in the parenchyma of the gland. To create a negative pressure, the piston is pulled back, as a result, the material is drawn into the needle. Then, having fixed the piston, which, as a result of negative pressure in the syringe, tends to take its original position, the syringe with the needle is removed from the tissues. The material from the needle and syringe is transferred to a glass slide and stained. Diagnostic puncture is used for differential diagnosis of tumors, inflammatory diseases of the salivary glands, specific processes, lymphadenitis, etc.

Biopsy of minor salivary glands(Fig. 19), the material is more often taken through a longitudinal incision of the mucous membrane of the lower lip (vertically to the transitional fold), since in this case it is parallel to the course of the vessels and nerves. However, some authors propose to make a horizontal incision 1 cm long closer to the corner of the mouth - parallel to the course of the muscle fibers of the circular muscle of the mouth. Then, in a blunt way, 4-5 small salivary glands are isolated and removed. The material is placed in a formalin solution and sent to the histological laboratory. This method is one of the main ones in the diagnosis of Sjögren's disease. The detection of lymphohistiocytic infiltrate in the amount of more than 50 cells per 4 mm 2 is defined as the focus of inflammation. The presence of foci of inflammation in several lobules is characteristic of Sjögren's disease. Two stains are usually used: hematoxylin-eosin and Van Gieson, as well as a histochemical PAS reaction to determine neutral mucopolysaccharides. It is noted that morphological changes in the minor salivary glands are identical to those in the major salivary glands. However, with Sjogren's disease, sarcoidosis, there is some lag

Rice. Fig. 19. Biopsy of the minor salivary glands from the submucosal layer of the lower lip: a - the incision line is marked, infiltration anesthesia; b - incision of the mucous membrane; c - minor salivary glands were isolated from the submucosal layer; d - at least five minor salivary glands were sampled; e - histological picture (hematoxylin-eosin x200)

changes in the small salivary glands compared to the large ones (parotid salivary gland), which may delay the timely diagnosis of these diseases.

A biopsy of the major salivary glands is performed in difficult diagnostic cases. This method is also used to diagnose lymphomas in Sjögren's disease. The material is taken from the tissue of the salivary gland through an incision on the skin that surrounds the earlobe. The material is examined according to the generally accepted method, often using immunophenotyping.

Radiosialographic study(Fig. 20) consists in registering and recording in the form of curves of the intensity of radioactive radiation simultaneously over the salivary glands and the heart. A patient on an empty stomach is injected intravenously with 100-110 mBq of sterile sodium pertechnetate [ 99m Tc]. Registration of radiation is carried out for 60 minutes. 30 minutes after the start of the study, a salivation stimulator (5 g of sugar) is injected into the patient's mouth.

Rice. 20. Radiosialogram (dynamic scintigraphy)

(Yudin L.A., Kondrashin S.A.): 1 - vascular segment; 2 - concentration segment; 3 - excretory segment; 4 - the second concentration segment; 5 - time of maximum accumulation of the radiopharmaceutical; 6 - "plateau"; 7 - the peak of the rise in radioactivity at the time of taking the stimulant; 8 - percentage of the maximum fall in radioactivity; 9 - time of the excretory segment

It is not necessary to use all methods in the diagnosis of pathology of the salivary glands. The choice of additional research methods is determined by clinical data. You should start with simple ones, then move on to more complex ones, but in some cases, the early appointment of special research methods, such as ultrasound (ultrasound) or magnetic resonance imaging (MRI), significantly speeds up the diagnosis, in particular of volumetric formations.

Questions for self-control

1. Features of the general examination of patients: questioning, examination, palpation, blood and urine tests.

2. List private survey methods.

3. How is the probing of the salivary gland duct performed?

4. What does the x-ray method of examination reveal in diseases of the salivary gland?

5. Methods for studying the secretory function of the salivary gland.

6. How is the quantitative analysis of salivary gland function performed?

7. Criteria for quantitative analysis of salivary gland function in normal and pathological conditions.

8. What is determined during a cytological examination of saliva taken from the duct of the salivary gland?

9. How is sialography performed and what does it give in the diagnosis of diseases of the salivary glands?

10. What is pantomosialography?

11. Name the special methods of examination of the salivary gland.

12. What are the indications and how is a histological examination of the minor salivary glands performed?

Situational tasks

Task 1

Patient K., 50 years old, complains of profuse salivation that appeared more than a year ago. Located on dis-

panserny account at the neuropathologist concerning pituitary adenoma.

Objectively: on palpation, the salivary glands are not enlarged, soft, painless. The opening of the mouth is free. Pure saliva is secreted from the mouths of the excretory ducts of the OUSZh, PChSZh. There is a lot of free saliva in the oral cavity. The mucous membrane of the oral cavity is abundantly moistened.

Questions:

1. What method of examination of the salivary glands should be carried out to clarify the diagnosis?

2. How is this study performed?

3. What other methods of sialometry exist?

4. What method is an alternative to sialometry?

5. What is the treatment strategy for this patient?

Task 2

Patient Zh., 25 years old, complains of short-term periodic swelling under the lower jaw on the left, which is aggravated during meals.

Anamnesis: swelling bothers for 2 weeks, disappears on its own after 15 minutes, no rise in temperature was noted.

Objectively: at the time of examination, the configuration of the face was not changed, the opening of the mouth was free. Large salivary glands are not enlarged. Bimanual palpation along the excretory duct of the left submandibular salivary gland in its middle part reveals a slightly painful focus of compaction. A transparent secret is released from the mouth of the excretory duct. Preliminary diagnosis: salivary stone disease.

Questions:

1. What method of additional examination should I start with?

2. In what projections is X-ray examination performed?

3. How might a salivary stone look like on a sialo-gram?

4. What method should be carried out to exclude small stones in the parenchyma of the gland and multiple calculi?

5. Is sialometry necessary in this case?

Task 3

Patient K., 60 years old, complains of dry mouth and painless enlargement of the parotid salivary gland (PSG). These symptoms have been disturbing for three years.

From the anamnesis it was found out that he suffers from rheumatoid arthritis. She is under the supervision of a rheumatologist.

Questions:

1. What preliminary diagnosis can be assumed?

2. What methods of examination should be carried out to establish the diagnosis?

3. How is sialometry performed?

4. How to perform sialography for a patient?

5. Technique of biopsy of minor salivary glands.

Answers to situational tasks

Task 1

1. Sialometry.

2. Method T.B. Andreeva: before the study, the patient is given inside 8 drops of a 1% solution of pilocarpine, after 20 minutes a metal cannula or a polyethylene catheter is inserted into the gland duct. Within 20 minutes, saliva is taken into a measuring tube.

3. Collection of mixed and ductal saliva, stimulated and unstimulated. Another method of collecting saliva: a Lashli-Yushchenko-Krasnogorsky capsule is applied to the mouth of the duct. Within 5 minutes, saliva is collected in a measuring tube.

4. Radiosialography.

5. Treatment of pituitary adenoma. After its removal, if hypersalivation is true, prescribe X-ray therapy.

Task 2

1. X-ray.

2. Mandatory in two projections: lateral and axial (floor of the mouth, in the bite).

3. In the form of a filling defect, or increased contrast, an area with clear contours that extends beyond the duct.

4. Ultrasound.

5. For diagnostic purposes - no. Task 3

1. Sjögren's syndrome.

2. Sialometry, SIAL sialography, biopsy of minor salivary glands.

3. With the help of the Leshli-Yushchenko-Krasnogorsky capsule.

4. With the help of probes of different diameters, the ductus duct is bougie. A water-soluble radiopaque substance - omnipak-350 is injected into the duct through a metal cannula until the gland is slightly bursting. X-rays of the OUSZh are performed in frontal and lateral projections.

5. Small salivary glands are taken from the submucosal layer of the lower lip. First, a longitudinal incision of the mucous membrane with a length of 1.5-2 cm is carried out, then several small salivary glands are isolated and removed. Place them in a formalin solution. The wound is sutured with interrupted sutures.

Tests for self-control

Choose one or more correct answers.

1. Private methods are used when examining patients:

1) all;

2) with pathology of certain organs;

3) with inflammatory diseases;

4) with dystrophic diseases;

5) with suspected oncological disease.

2. The length of the parotid salivary glands in an adult (cm):

1) 2-3;

2) 4-6;

3) 6-8;

4) 8-10;

5) 11-12.

3. Normally, large salivary glands:

1) palpated;

2) are not palpated;

3) are determined visually;

4) are determined when the head is tilted back;

5) are significantly increased.

4. The excretory duct of the parotid salivary gland is called:

1) stenons;

2) Whartons;

3) bartholinians;

4) Walters;

5) Wirsungs.

5. The excretory duct of the submandibular salivary gland is called:

1) stenons;

2) Whartons;

3) bartholinians;

4) Walter;

5) Wirsungs.

6. The excretory duct of the sublingual salivary gland is called:

1) stenons;

2) Whartons;

3) bartholinians;

4) Walters;

5) Wirsungs.

7. The duct of the parotid salivary gland opens on the mucous membrane:

1) cheeks;

2) upper lip;

3) lower lip;

4) soft palate;

5) floor of the mouth.

8. The duct of the parotid salivary gland opens at the level of:

1) upper third molar;

2) lower first molar;

3) upper first molar;

4) upper first premolar;

5) upper second premolar.

9. The excretory ducts of the sublingual and submandibular salivary glands open on the sublingual papilla:

1) always by a common duct;

2) common duct in 95% of cases;

3) always separately;

4) a common duct of 50%;

5) a common duct of 30%.

10. Normally, the secret of the ducts of the large salivary glands:

1) transparent;

2) cloudy;

3) with mucous lumps;

4) with strand inclusions;

5) with flaky inclusions.

11. Atresia of the salivary duct is:

1) its absence;

2) dystopia;

3) narrowing;

4) infection;

5) cyst.

12. Complaints in the initial stage of xerostomia on:

1) a feeling of dryness of the oral mucosa when talking;

2) constant dryness of the oral cavity;

3) pain during eating;

4) progressive destruction of teeth;

5) erosion on the oral mucosa.

13. With sialometry according to the method of T.B. Andreeva is isolated from the parotid salivary gland (ml):

1) 0,5-1;

2) 1-3;

3) 3-5;

4) 5-7;

5) 7-10.

14. With sialometry according to the method of T.B. Andreeva from the submandibular salivary gland is isolated (ml):

1) 0,5-1;

2) 1-4;

3) 4-6;

4) 6-8;

5) 8-10.

15. Time of saliva sampling according to the method of T.B. Andreeva (min):

1) 5;

2) 10;

3) 15;

4) 20;

5) 30.

16. For objective confirmation of xerostomia use:

1) sialography;

2) cytological examination;

3) salivary gland biopsy;

4) sialometry;

5) probing the ducts.

17. With xerostomia in a clinically pronounced stage, a decrease in salivation is noted (ml):

1) 0;

2) 0-0, 2;

3) 0,3-0,8;

4) 1-1,5;

5) 1,5-2.

18. Average fluctuations in the rate of excretion of mixed saliva at rest (ml / min):

1) 0,1-0,15;

2) 0,3-0,4;

3) 1-2;

4) 3-4;

5) 4-5.

19. When stimulated by chewing paraffin, the rate of release of mixed saliva increases to (ml / min):

1) 0,1-0,15;

2) 0,3-0,4;

3) 1-2;

4) 3-4;

5) 4-5.

20. 1% solution of pilocarpine hydrochloride to stimulate salivation:

1) M-anticholinergic;

2) M-cholinomimetic;

3) β 1 - adrenomimetic;

4) β 1 -blocker;

5) blocker of histamine receptors.

21. Sialotomography is:

1) subtraction sialography;

2) sialography with direct image magnification;

3) layer-by-layer X-ray examination of the salivary glands after filling the ducts with a contrast agent;

4) scanning of the salivary glands;

5) thermovisiography.

22. Normally on the mucous membrane of the lower lip (in area 2 x 2 cm) functioning minor salivary glands:

1) 10±1.0;

2) 16±1.0;

3) 21±1.0;

4) 35±1.0;

5) 40±1.0.

23. Lashley-Yushchenko-Krasnogorsky capsule:

1) single-chamber;

2) two-chamber;

3) three-chamber;

4) four-chamber;

5) five-chamber.

24. Lashli-Yushchenko-Krasnogorsky capsule is used when saliva is taken from (salivary glands):

1) parotid;

2) parotid and submandibular;

3) submandibular;

4) sublingual;

5) small.

25. Sialometry of minor salivary glands is performed using:

1) cannulas;

2) capsules;

3) suction with a syringe;

4) weighing cotton swabs;

5) visually.

26. To fill the ducts of the unchanged parotid salivary gland, a contrast agent is required (ml):

1) 1-2;

2) 3-4;

3) 5-6;

4) 6-7;

5) 7-8.

27. A defect in the filling of the parenchyma of the salivary gland on the sialogram looks like:

1) a stain of a contrast agent with clear contours;

2) a stain of a contrast agent without clear contours;

3) parenchyma area with no contrast enhancement;

4) release of the contrast agent outside the ducts;

5) multiple sialoectasias.

28. If you suspect the presence of a stone in the submandibular salivary gland, first of all, the following is performed:

1) computed tomography;

2) magnetic resonance imaging;

3) x-ray examination in 2 projections;

4) cytological examination of the secret;

5) histological examination.

29. For cytological examination, a drop of salivary gland secretion is stained according to:

1) Ziel-Nielsen;

2) Romanovsky-Giemsa;

3) the Moeller method;

4) Neisser;

5) Gram.

30. Cytological examination of the ductal secretion of the salivary glands normally determines:

1) single cells of squamous and cylindrical epithelium, acellular detritus;

2) squamous epithelial cells, neutrophilic leukocytes and lymphocytes;

3) cell layers of squamous and cylindrical epithelium, goblet cells;

4) abundance of squamous, cylindrical, cubic epithelium, goblet cells, neutrophils in the stage of degeneration;

5) accumulations of lymphoid elements and goblet cells.

31. The cytological picture of mixed saliva in Sjögren's disease is characterized by:

1) the appearance of goblet cells;

2) scarcity of cellular elements;

3) the appearance of bare nuclei;

4) an increase in the cells of the deep layers of the epithelium (intermedial type);

5) the appearance of atypical cells.

32. Yodolipol is:

1) water-soluble contrast agent;

2) fat-soluble contrast agent;

3) salivation stimulator;

4) radiopharmaceutical;

5) M-anticholinergic.

1) omnipack-180;

2) omnipack-240;

3) omnipack-300;

4) omnipack-350;

5) all drugs.

34. International name of omnipack:

1) bignost;

2) ultravist;

3) bilimin;

4) iohexol;

5) propyliodon.

35. When performing sialography with fat-soluble contrast agents, the following complications are possible:

1) injury of the duct with the release of contrast into the parenchyma;

2) prolonged retention of the contrast agent in the ducts and parenchyma;

3) development of a cellular reaction involving lymphocytes and histiocytes and further periductal fibrosis;

4) the formation of foreign body granulomas with multinucleated giant cells.

36. The width of the parotid duct is normal (mm):

1) 1-2;

2) 2-3;

3) 4-5;

4) 6-7;

5) 8-9.

37. In the clinically pronounced stage of Sjögren's disease on the sialogram, cystic cavities have the following size (mm):

1) up to 1;

2) 1-5;

3) 5-10;

4) 10-15;

5) 15-20.

38. When performing functional digital subtraction sialography, injects into the ducts of the gland:

3) radioactive Tc;

4) radioactive I;

5) radioactive Ga.

39. During a radiosialographic examination, the following is administered intravenously to a patient on an empty stomach:

1) fat-soluble contrast agent;

2) water-soluble contrast agent;

3) radioactive Tc;

4) radioactive I;

5) radioactive Ga.

40. Evacuation of a water-soluble contrast agent from the parenchyma and ducts of unaffected parotid salivary glands is:

1) 40-50 s;

2) 1-2 min;

3) 3-4 min;

4) 5-6 minutes;

5) 7-8 min.

Answers to tests for self-control

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Projection of the excretory duct of the parotid gland. Tumors of the parotid salivary gland. The structure of the salivary glands

Functions

Other diseases

Why is it inflamed?

Treatment

Complications

Prevention

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Types and functions

Minor salivary glands

Major salivary glands

parotid gland

Submandibular salivary gland

sublingual salivary gland

Diseases of the salivary glands

Treatment

Conclusion

Embryology

Anatomy

X-ray anatomy

Research methods

Chapter 2

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