Surgical results of the intraoral removal of the submandibular gland

OBJECTIVES: Most patients with benign submandibular disorders have been treated surgically without difficulty via the transcervical approach. An alternative to the standard transcervical approach has been reported such as an intraoral approach. SUBJECTS AND METHODS: Retrospective chart review of the 77 patients with benign submandibular disorders. All patients underwent an excision of the submandibular gland via intraoral approach. RESULTS: Early postoperative complications developed in 74.0% of the temporary lingual sensory paresis followed by 70.1% of temporary limitation of tongue movement. However, these complications soon resolved in all patients spontaneously. Two cases of postoperative bleeding and 1 case of abscess formation were developed. Whereas late complications developed in 4 cases of residual salivary gland and abnormal sense of mouth floor and 1 case of gustatory sweating (Frey's) syndrome. CONCLUSION: The major advantages of this approach are no external scar, no injury to the marginal mandibular nerve. The disadvantage is a more difficult dissection to transcervical approach before proper expert, especially in the severe adhesion of salivary gland to surrounding tissue.     

Postauricular incision versus conventional transcervical incision in submandibular gland excision: A systematic review and meta-analysis

Surgical removal of the submandibular gland is indicated for different conditions affecting the gland, such as neoplasm, sialadenitis, and sialolithiasis, and different types of surgical approaches have been reported. The purpose of this meta-analysis was to evaluate the differences between the postauricular approach and conventional transcervical approach in submandibular gland excision. A systematic review was performed using PubMed, Embase and the Cochrane Library to identify studies comparing outcomes of submandibular gland surgery via the postauricular approach and conventional transcervical approach. The data of interest were analyzed with Comprehensive Meta-Analysis software (version 3; Biostat, Englewood, NJ). Dichotomous data and continuous data were analyzed by calculating the risk difference (RD) and the mean difference (MD) with the 95% confidence interval (CI), respectively. The results show that the postauricular incision is a feasible approach to access the submandibular gland, and compared with the conventional transcervical approach, it requires a longer operative duration but has a similar complication rate and yields better cosmetic outcomes.     

Minimally invasive video-assisted submandibular sialadenectomy: surgical technique and results from two institutions

Background

Submandibular gland excision is traditionally performed using a transcervical approach. However, innovative surgical trials have recently been conducted to investigate techniques that can prevent or reduce visible scarring and nerve injury. The aim of the present study was to evaluate the feasibility of a new approach to submandibular gland excision that is based on the use of a minimally invasive video-assisted technique and an ultrasound scalpel in an endoscopic neck surgery program with a low annual flow of procedures.

Methods

We retrospectively studied 15 patients with submandibular gland disease who underwent minimally invasive video-assisted submandibular sialadenectomy performed by two surgeons at two institutions. Eight patients had proximally located salivary calculi, three had chronic sialadenitis, and four had benign neoplasms. All dissections were carried out by a single-port gasless approach, using the Miccoli technique, involving endoscope magnification and an ultrasonic scalpel.

Results

All 15 submandibular gland resections were performed successfully, with no conversions to conventional open resection. The operative time ranged from 45 to 125 min (median 84 min). A total of 67 % of patients were discharged the day after surgery, and the maximum length of stay was 3 days. One patient experienced postoperative bleeding, and one experienced postoperative infection. There was no neural injury. The incision scar healed well in all cases, and all patients reported excellent cosmetic results.

Conclusions

Endoscopic submandibular gland resection using a minimally invasive video-assisted technique, endoscopic magnification, and ultrasonic scalpel was feasible and resulted in excellent surgical outcomes.

     

Submandibular gland excision. Clinical experience

Submandibular gland excision is proposed for the treatment of both neoplastic and non-neoplastic diseases. This study examines four cases of patients who underwent submandibular gland excision performed by the transcervical approach: two cases of non-neoplastic disease (one sialolithiasis and one chronic sialoadenitis not correctly assessed by sonography), one case treated for chronic sialoadenitis who developed a non-Hodgkin lymphoma involving the oral mucosa, and one case with a benign neoplastic lesion (pleomorphic adenoma). The symptoms, physical findings, and diagnosis on pathological examination are discussed in each case. On the basis of the literature, the indications for submandibular transcervical excision and the postoperative neurological complications are discussed, emphasising that only a detailed knowledge of the anatomy of the region can reduce the morbidity of this operation.     

Management of pediatric ranula.

OBJECTIVE: Many surgical techniques to manage ranulas have been described in the literature. These techniques include excision of the cyst with or without excision of the ipsilateral sublingual gland, marsupialization, cryosurgery, and CO(2) laser excision. Few studies have described the approach toward management in pediatric patients. METHODS: Six patients were treated for intraoral ranulas. Two patients had spontaneous resolution of their lesions. Four patients required dissection of the submandibular duct and lingual nerve to completely excise an oral cavity ranula and an ipsilateral sublingual gland. RESULTS: There were no recurrent lesions. One patient developed a lingual nerve injury but no numbness. The 2 patients with spontaneous resolution did not develop a subsequent lesion. CONCLUSION: Optimal management of pediatric oral cavity ranulas may include observation for 5 months for spontaneous resolution. If the lesion does not resolve or recurs repeatedly, surgical treatment is recommended. Submandibular duct dissection with relocation appears to enhance exposure to the floor of mouth. The pseudocyst and entire sublingual gland should be removed. Identification of the lingual nerve is necessary to accomplish this goal.     

Trans-oral robotic submandibular gland removal

Submandibular gland excision is traditionally performed via a trans-cervical approach. While generally regarded as a relatively simple surgical procedure, several complications are possible, including injury to the marginal mandibular branch of the facial nerve, lingual nerve, hypoglossal nerve, facial artery and a visible unsightly neck scar or keloid. The trans-oral route has the ability to eliminate a cervical scar and decrease risk of injury to several structures. Coincident with the development of the trans-oral approach, robotic surgery has been gaining popularity in the operative management of early oral cavity, tonsil, and tongue base malignancies. A 51-year-old female presented to our institution with a 15-year history of recurrent left submandibular gland sialoadenitis. She previously underwent a rhytidectomy with cervicoplasty and was interested in a trans-oral approach to avoid a neck incision. Here we present a novel application of the da Vinci Surgical Robot for trans-oral removal of the submandibular gland.     

PAROTID AND SUBMANDIBULAR SIALADENITIS TREATED BY SALIVARY GLAND EXCISION

Background : The purpose of the present study was to compare and contrast the clinicopathological features and treatment outcome of chronic sialadenitis involving the parotid and submandibular glands, among patients who were treated by excision of the affected gland. Methods : In a series of 88 patients treated over an 8-year period, 47 had parotid sialadenitis and 41 had submandibular sialadenitis. In the parotid group, 63% of patients were symptomatic for longer than 6 months compared with 27% in the submandibular group. Calculi were implicated in the disease process in 24% of patients with parotid sialadenitis, compared with 73% of patients with submandibular disease. Results : Patients with parotid sialadenitis had superficial (n= 14) or near-total parotidectomy (n= 35), while those with submandibular sialadenitis underwent total gland excision. Complications occurred twice as frequently in the parotidectomy group. The rate of temporary facial nerve weakness was 29% after parotidectomy while marginal mandibular nerve dysfunction occurred after 12% of submandibular excisions. Both procedures were highly effective in permanently relieving the symptoms of sialadenitis. Conclusions : Parotid sialadenitis is infrequently associated with stones and tends to run a longer course before surgical intervention is necessary. Submandibular sialadenitis usually presents earlier, is secondary to calculi and requires early intervention.     

Surgical management of sialorrhea

Sialorrhea is a distressing problem in children with cerebral palsy, in children with other neurologic disorders, and in normal children. The constant need for clothing or bib changes in handicapped patients frequently results in further social isolation and causes normal children to be viewed as "impaired." The surgical treatment of sialorrhea at Children's Hospital Medical Center, Cincinnati, Ohio, has evolved over the past 5 years. Since 1981, 70 surgical procedures have been performed for drooling at this institution; follow-up information is available on 52 patients. The surgical procedures performed included submandibular rerouting alone, submandibular duct rerouting with bilateral tympanic neurectomy with bilateral submandibular gland excision, and bilateral submandibular gland excision with bilateral parotid duct ligation. Our review indicates that bilateral submandibular gland excision with parotid duct ligation is the only procedure in which consistent control of sialorrhea can be expected. Postoperative complications after this procedure were minimal and only one parent complained that the child had a dry mouth after the procedure. Postoperative hospitalization after bilateral submandibular gland excision and bilateral parotid duct ligation was not significantly different from that required after any of the other procedures. In conclusion, this surgical procedure appears to be the most effective surgical treatment for sialorrhea and precludes the need for multiple operative procedures for this problem.     

Submandibular gland surgery: an audit of clinical findings,pathology and postoperative morbidity.

A series of 86 patients who underwent submandibular gland surgery were reviewed retrospectively. Of the 92 glands excised, non-neoplastic disease accounted for 96% of cases. Preoperative clinical findings were inconsistent such that early surgery should be considered for an enlarged non-tender submandibular gland. The incidence of temporary paresis of the lower branches of the facial nerve was 36% with full recovery, on average, 4 months after surgery. The low ''non-identification'' approach to the submandibular gland appears to be the technique which offers the least likelihood of permanent damage to the lower branches of the facial nerve.     

Video-assisted transcervical thymectomy

Background The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described.Methods Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space.Results No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study.Conclusion Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.     

Neurinoma of the hypoglossal nerve in the submandibular space: case report and review of the literature

Summary Neurinomas of the hypoglossal nerve extending extra-cranially are rare; a schwannoma in a 63-year-old woman causing nerve palsy is reported. The tumour presented as a slow-growing mass in the right submandibular space; a surgical approach with transcervical exploration was performed. The post-operative course was uneventful.     

Follicular carcinoma in ectopic thyroid gland. A case report

Ectopic thyroid rest can be seen anywhere along the path of descent of the gland. The most ectopic thyroid tissue is a thyroglossal duct cyst associated with normal thyroid gland. Sublingual location is less common than a lingual ectopia. True malignant transformation in ectopic thyroid tissue is extremely rare. Such a malignancy is virtually always diagnosed only after surgical excision of the lesion at pathological examination. This report discusses a case of ectopic thyroid follicular carcinoma in the right submandibular region in the absence of orthotopic thyroid, discovered by chance after the surgical excision performed for a preoperative ultrasonically and cytologically misdiagnosed submandibular gland adenocystic carcinoma. The possible aetiology of such an unusual anatomical relationship is discussed as well as the importance of thyroid scanning, ultrasound and/or CT in neck lumps.     

Schwannoma of the submandibular gland

Neurilemmomas (schwannomas) are solitary neurogenic tumors that arise from cells of the neural sheath. They are slow growing and represent a proliferation of Schwann cells. Extracranial neurogenic tumors of the head and neck are uncommon, with benign tumors occurring with greater frequency than malignant tumors. These tumors often mimic primary or metastatic disease in the head and neck. Schwannoma of the salivary gland is a particularly rare form of an extracranial neurogenic tumor, with most presenting in the parotid gland originating from a peripheral branch of the facial nerve. An unusual case of neurilemmoma of the submandibular gland is presented, and the literature concerning this subject is reviewed. We believe this tumor originated in an autonomic nerve of the submandibular gland. The mass was discrete and well demonstrated on CT scan. Total excision of the gland resulted in complete resolution of symptoms with no cranial nerve deficits.     

Submandibular duct relocation for drooling: a 10-year experience with 194 patients

Management of drooling in the neurologically disabled individual has been accomplished with a team approach using surgical and nonsurgical methodology. Submandibular duct relocation has been the primary surgical procedure of choice in 194 patients during the past 10 years. Drooling has been reduced significantly in the majority of patients. Ranulas requiring intraoral sublingual gland excision occurred in 8% of patients. Persistent submandibular duct obstruction necessitating external excision of the submandibular gland occurred in 1% of the ducts relocated.     

Excision of the submandibular gland: minimizing the risk of nerve damage

Surgical texts do not clearly advise whether the ramus mandibularis should be identified in excision of the submandibular salivary gland for benign disease. An analysis of 74 patients was undertaken to assess the subsequent nerve function after submandibular salivary gland excision. Both glands were removed in two patients, making the total number of glands excised 76. In five cases the nerve was identified, in five patients the operative record did not clearly state whether the nerve was identified, and in the remaining 66 a non-identification technique was used. The subsequent analysis was unable to follow-up six patients fully. Seven patients had mild to moderate weakness in the early postoperative period, but all recovered, some taking up to 3 months to do so. Other complications were minor, except for two patients who had postoperative haemorrhage, one requiring a tracheostomy. As the majority of these patients had a non-identification technique, and because searching for the nerve is tedious and time-consuming, the former approach is recommended when operating for benign disease of the submandibular salivary gland.     

The Diagnostic Dilemma of a Parasympathetic Schwannoma in the Submandibular Gland

Schwannomas are benign soft tissue tumours that arise from nerve sheath cells. They are rare in the salivary glands and are thought to arise from the parasympathetic nerves. We report the case of a 69-year-old man who presented with a painless right submandibular mass that appeared to resemble a pleomorphic adenoma on ultrasonography and, on this basis, proceeded to surgical excision of the gland. We review the relevant literature and highlight the diagnostic pitfalls.     

Minimally invasive endoscopic resection of the submandibular gland: a new approach

BACKGROUND: This study evaluates the benefits of a new approach, endoscopic resection of the submandibular gland through the hyoid midline level skin incision by use of an ultrasonically activated scalpel. METHODS: Twelve operations for patients presenting with submandibular gland disease were performed via minimally invasive endoscopic resection by a single surgeon (M-KC). RESULTS: All 12 submandibular gland resections were successfully performed endoscopically, and no conversions to conventional open resection were necessary. Of the 12 patients who underwent excision, 3, 6, and 3 had mixed tumor, sialoadenitis with sialolithiasis, and chronic sialoadenitis, respectively. The procedures lasted 50 to 125 minutes (median duration, 70 minutes). No complications associated with the operation occurred, and the scar was almost invisible because of its concealed location with the neck in the natural position. CONCLUSIONS: Endoscopic resection of the submandibular gland is a feasible method for treatment of benign lesions. The main advantages of this procedure are that the small operative scar is concealed in the submental skin crease, resulting in improved cosmetic results and minimization of the possibility of facial nerve injury.     

Pediatric submandibular triangle masses: a fifteen-year experience

BACKGROUND: The purpose of this study was to evaluate the surgical results of pediatric submandibular triangle masses, with specific attention to neoplastic processes. METHODS: We retrospectively reviewed the medical records of 105 patients aged 6 months to 21 years who underwent surgery in the submandibular triangle at a major pediatric tertiary care hospital from 1987 to 2001. RESULTS: One hundred five patients who underwent surgery in the submandibular triangle were included in the study. Twenty patients had neoplastic processes, six of which were of primary salivary origin (two mucoepidermoid carcinomas and four pleomorphic adenomas). Twenty-four patients underwent excision of inflamed or infected lymph nodes, and 23 patients underwent excision of inflamed or infected submandibular glands. Thirty-eight patients were included who underwent surgery for sialorrhea or to gain access for another surgical procedure. Complications included tumor recurrence, transient and permanent marginal mandibular nerve weakness, ranula, postoperative fluid collection, and cellulitis. Duration of follow-up ranged from no follow-up to 11 years. CONCLUSION: Surgical excision of submandibular triangle masses is uncommon. We present our experience with these lesions, with a discussion of diagnosis, surgical indications, and surgical complications.     

Transcutaneous excision of the submandibular and sublingual glands: notes on anatomy and surgical technique

Removal of the submandibular and sublingual glands requires in-depth knowledge of the anatomy and scrupulous technique for the purposes of limiting the functional and aesthetic damage, which is unjustifiable above all in the treatment of benign lesions (sialodenitis, lithiasis). After presenting the main aspects of the surgical anatomy of the submandibular space, the operative technique for its dissection with removal of the submandibular gland and excision of the sublingual gland is described. The complexity of the anatomical structures that may be involved in submandibular and sublingual gland lesions is the cause of unsatisfactory functional and aesthetic outcomes in some cases. The most feared complications are lesions to nerve formations, due both to the resulting deficits and the possible legal implications.     

Marginal mandibular branch of the facial nerve: An anatomical study

Smile is one of the most natural and important expressions of human emotion. Man uses his lips mainly to register his emotions. Thus, the slightest asymmetry or weakness around the lips and mouth may transform this pleasant expression into embarrassment and distortion. The circumoral musculature, the major part of which is supplied by the marginal mandibular branch of the facial nerve, is the main factor in this expression. Therefore, an injury to this nerve during a surgical procedure can distort the expression of the smile as well as other facial expressions. This nerve often gets injured by surgeons in operative procedures in the submandibular region, like excision of the submandibular gland due to lack of accurate knowledge of variations in the course, branches and relations. In the present study, 50 facial halves were dissected to study the origin, entire course, termination, branches, muscles supplied by it, its anastomoses with other branches of facial nerve on the same as well as on the opposite side and its relations with the surrounding structures. The marginal mandibular branch of the facial nerve was found superficial to the facial artery and (anterior) facial vein in all the cases (100%). Thus the facial artery can be used as an important landmark in locating the marginal mandibular nerve during surgical procedures. Such a study can help in planning precise and accurate incisions and in preventing the unrecognized severance of this nerve during surgical procedures.