Anatomy, Head and Neck, Sublingual Gland

Article Author:
Jeewanjot Grewal
Article Author (Archived):
Bruno Bordoni
Article Editor:
Jesse Ryan
Updated:
12/13/2018 1:39:44 PM
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Anatomy, Head and Neck, Sublingual Gland

Introduction

The sublingual gland is the smallest of the three major salivary glands, which also include the parotid and submandibular glands. The sublingual gland lies between the muscles of the oral cavity floor, which include the geniohyoid muscle, hyoglossus muscle medially, and the mylohyoid muscle inferiorly. The mandible borders the sublingual glands laterally.[1]

The ducts of Rivinus, a group of excretory ducts, drain the sublingual gland. The largest sublingual gland excretory duct called the sublingual duct of Bartholin joins Wharton’s duct near the sublingual caruncle. The sublingual caruncle is a papilla located medial to the sublingual gland and lateral to the lingual frenulum.[1]  The sublingual gland contributes approximately 5% of saliva in the oral cavity.[2]

Structure and Function

The sublingual glands lie inferolateral to the tongue, below the floor of the mouth mucosa, and above the mylohyoid muscle. Sublingual tissue is palpable behind the mandibular canines. The sublingual gland takes an oval shape when sectioned transversely, however, the gland shape is longitudinal and lentiform when sectioned parallel to the body of the mandible. [1]

The sublingual gland differs from the other major salivary glands, because it lacks intercalated or striated ducts, so the saliva secretes directly through the ducts of Rivinus. These ducts empty along an elevated ridge called the plica fimbriate formed by the sublingual folds, which are oblique to the frenulum linguae bilaterally. The sublingual duct of Bartholin joins Wharton’s duct to form the draining orifice on each side of the lingual frenulum.[3]

The sublingual tissue is predominantly a mucous gland, however, is considered a mixed serous and mucous gland. It is made up of mainly mucous acini with serous demilunes. It is the only unencapsulated major salivary gland. Sublingual tissue primarily produces a thick mucinous fluid and lubricates the oral cavity which allows for swallowing, initiating digestion, buffering pH, and dental hygiene.[2]  

The composition of saliva depends on the salivary flow rate and can vary given each gland's flow rate and overall contribution. Saliva is comprised of both organic and inorganic components. Inorganic components include electrolytes, urea, and ammonia. The organic elements of saliva contain immunoglobulins, enzymes, and proteins.[2]

The primary protein found in mucous saliva is mucin, which functions to lubricate and competitively inhibit bacterial attachment to the salivary duct epithelium. This action allows for antimicrobial protection of the sublingual gland.[2]

Embryology

The sublingual gland develops later than the other major salivary glands as it first appears in the eighth week of prenatal development. The sublingual gland originates from epithelial buds surrounding the sublingual folds on the floor of the mouth. These epithelial buds develop into cords, which canalize to form the sublingual ducts and also form the mucous acini. Initially, the sublingual gland develops laterally to the submandibular gland before transitioning to a position anterior and superior to the submandibular gland when development is complete.[3]

Blood Supply and Lymphatics

Blood supply

The sublingual glands receive its primary blood supply from the sublingual and submental arteries, which are branches of the lingual artery and facial artery, respectively. These arteries are both branches of the external carotid artery. The sublingual vein drains into the lingual vein, which then flows into the internal jugular system.

Lymphatics

The sublingual glands drain into the submandibular lymph nodes. The submandibular lymphatics comprise 3-6 nodes, which are located in the submaxillary triangle, beneath the body of the mandible. The nodes are palpable on the superficial surface of the submandibular gland. Malignant tumors may drain into these regional lymph nodes, requiring more extensive neck dissection for the complete treatment of cancer. 

Nerves

The sublingual glands receive their parasympathetic input via the chorda tympani nerve, which is a branch of the facial nerve via the submandibular ganglion. The nerve functions in a secretomotor capacity. The chorda tympani branches from the motor branch of the facial nerve in the middle ear cavity, which then exits the middle ear through the petrotympanic fissure. The chorda tympani nerve then travels with the lingual nerve to synapse at the submandibular ganglion. The postganglionic fibers reach the sublingual gland, and release acetylcholine and substance P. Acetylcholine, the primary neurotransmitter, and the muscarinic receptors work to increase salivation.[3]

Muscles

The sublingual gland is positioned above the mylohyoid muscle and below the floor of mouth mucosa.

Surgical Considerations

An operation to excise the sublingual gland most commonly involves transoral electrocautery and blunt dissection. Structures most at risk of injury during gland excision are the lingual nerve and Wharton's duct. The sublingual tissue can be found in the anterior floor of the mouth and directly deep to Wharton’s duct.

Clinical Significance

Ranula

A ranula is a mucocele of the sublingual gland and can be described as simple or deep. Simple ranulas are mucous retention cysts located deep to the floor of the mouth but remain above the mylohyoid muscle. A deep or cervical ranula occurs when the sublingual duct is leaking, and the collecting mucous dissects through the mylohyoid muscle into the submental or lateral neck adjacent tissue planes, forming a pseudocyst. Both are usually caused by local trauma that damages the sublingual gland allowing mucous to collect. The ranula presents as a fluctuant, swollen mass at the floor of the mouth with a bluish tint. If larger, this may lead to dysphagia, however, it is usually painless unless infected. The ranula is primarily located lateral to the midline of the floor of the mouth, and this helps to distinguish its presentation from a dermoid cyst which usually presents in the midline.[4]

Diagnosis involves a thorough clinical history and physical exam. Ultrasound helps to differentiate between a simple or deep ranula as it can confirm the depth above or below the mylohyoid muscle and overall quality of the lesion. Ultrasound can also identify rupture or herniation of the sublingual gland. Treatment options include removal of the sublingual gland with ranula excision, marsupialization, or sclerotherapy. Excising the sublingual gland helps to minimize recurrence. This lesion usually presents in children and is the most common pathologic lesion of the sublingual gland.[4] 

Neoplasia

Neoplastic disease may affect the sublingual gland as 3% to 4% of head and neck cancers involve salivary glands. The larger the size of the gland, the higher the odds of a mass being benign.[2]

Sublingual gland tumors are usually malignant and comprise about 1.6% of all salivary gland malignancies. Adenoid cystic carcinoma and mucoepidermoid carcinoma count as the most common sublingual gland malignancies reported. Most tumors present with an asymptomatic floor of mouth swelling and present similarly to benign conditions making diagnosis difficult. Treatment course most commonly includes surgical tumor excision.  Neck dissection and radiation therapy may be indicated in advanced tumor staging or aggressive pathologies.[5]

Sialolithiasis

Salivary stones (calculi) obstructing an excretory duct is a common salivary gland disease. The pathophysiology of salivary calculi is related to salivary stasis and overall inflammation of the excretory duct. Salivary stones may cause swelling of the duct or gland causing a colicky peri-prandial pain. Salivary calculi are manually palpable when lodged in a duct. Ultrasound can aid diagnosis along with adjunctive CT or MR sialography if workup is negative, but suspicion remains high. Initial treatment is conservative, which comprises oral hydration and sialagogues. Surgery is only recommended when a conservative approach fails, and symptoms persist. Sialolithiasis mainly impacts the submandibular gland and rarely occurs in the sublingual gland. [2]

Sialadenitis

Acute sialadenitis refers salivary gland inflammation and may be caused by bacterial or viral infection. The inflammation may be accompanied with fever, pain, and gland swelling. If the etiology is a bacterial infection, then antibiotics are recommended. Otherwise, oral hydration and sialagogues are recommended. If the formation of an abscess complicates the infection, surgical intervention may be required. Chronic inflammation of the salivary glands can be related to recurrent infections, autoimmune conditions (e.g. Sjogren's syndrome) or radiation exposure. The sublingual gland is rarely affected by any of these acute or chronic problems in isolation. [2]

Other Issues

The use of interferential current stimulation has been investigated for patients who suffer from dry mouth. It may be an approach to stimulate the function of the sublingual and submandibular glands. This therapy modality does not create distress or pain for the patient.[6]



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References

[1] Bialek EJ,Jakubowski W,Zajkowski P,Szopinski KT,Osmolski A, US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls. Radiographics : a review publication of the Radiological Society of North America, Inc. 2006 May-Jun     [PubMed PMID: 16702452]
[2] Armstrong MA,Turturro MA, Salivary gland emergencies. Emergency medicine clinics of North America. 2013 May     [PubMed PMID: 23601484]
[3] Holmberg KV,Hoffman MP, Anatomy, biogenesis and regeneration of salivary glands. Monographs in oral science. 2014     [PubMed PMID: 24862590]
[4] Ugga L,Ravanelli M,Pallottino AA,Farina D,Maroldi R, Diagnostic work-up in obstructive and inflammatory salivary gland disorders. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. 2017 Apr     [PubMed PMID: 28516970]
[5] Andreasen S,Bjørndal K,Agander TK,Wessel I,Homøe P, Tumors of the sublingual gland: a national clinicopathologic study of 29 cases. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2016 Nov     [PubMed PMID: 27015666]
[6] Hasegawa Y,Sugahara K,Sano S,Sakuramoto A,Kishimoto H,Oku Y, Enhanced salivary secretion by interferential current stimulation in patients with dry mouth: a pilot study. Oral surgery, oral medicine, oral pathology and oral radiology. 2016 May     [PubMed PMID: 27017403]