Four-duct ligation: a simple and effective treatment for chronic aspiration from sialorrhea.

OBJECTIVES: To determine the effectiveness of bilateral submandibular and parotid duct ligation on children with severe neuromuscular impairment and chronic aspiration of salivary secretions and to identify any predictable anatomical connections between the submandibular duct and sublingual glands. DESIGN: Case series; retrospective anatomical study of adult cadaveric submandibular gland specimens. SETTING: Academic tertiary referral medical center. PATIENTS: Five children with severe neuromuscular impairment and recurrent aspiration pneumonitis. INTERVENTION: The children underwent bilateral submandibular and parotid duct ligation. The oral cavities of 8 cadavers were dissected to identify anatomical connections between the submandibular duct and sublingual glands. MAIN OUTCOME MEASURES: Incidence of postoperative aspiration pneumonitis; gross anatomical connections between the submandibular duct and sublingual gland in cadaveric specimens. RESULTS: No postoperative airway obstruction, infection, or xerostomia was noted, and technetium scanning confirmed control of salivary secretions from major salivary glands. Caregivers noted diminished salivary secretions and no aspiration pneumonia. CONCLUSIONS: This new, simple intraoral procedure controls aspiration pneumonitis with minimal surgical dissection and has less morbidity than procedures involving major salivary gland excision. Ranula formation, a common complication of submandibular duct transposition, is unlikely in this procedure because the sublingual ducts are not interrupted.     

Sialolithiasis in a residual Wharton's duct after excision of a submandibular salivary gland

Treatment of salivary stones includes both surgical and non-surgical techniques. Surgical approaches range from excision of the sialolith, for those near the duct orifice, to removal of the affected salivary gland and its associated duct, for stones near the hilum of the gland. We present a case of two sialoliths triggering an acute infection in a residual Wharton's duct, 12 years after the removal of the associated submandibular gland. Excision of the sialoliths and treatment of the infected duct via sialodochoplasty was successfully performed in this patient. If the Wharton's duct is not removed with the associated submandibular gland, the potential for infection and continuous growth of dormant calcifications exists. We also address the aetiology, pathogenesis, and management of patients with sialolithiasis in the absence of a major salivary gland.     

Parotid gland atrophy induced by occlusion of the ductal system with a protein solution

Nonneoplastic disorders of the parotid gland, such as chronic recurrent parotitis, asymptomatic gland enlargement, or salivary fistulae, are therapeutic problems. Surgical removal of the gland is often difficult, since scar tissue may be present in these benign diseases. Therefore, alternative treatment methods, such as ligation of Stensen's duct, irradiation, or tympanic neurectomy, have been used to induce atrophy of gland parenchyma. This goal can also be attained by intraluminal duct occlusion, which involves instillation of a resorbable protein solution into the duct system, a procedure similar to sialographic injection. Intraluminal duct occlusion is a simple technique with rapid onset of atrophy and low morbidity, and with its use options remain open for other treatment modalities. The authors have used this method in the treatment of various diseases in 26 parotid glands and one submandibular gland. Their experience, which includes three-year patient follow-up data, suggests that this technique may be a useful alternative to salivary gland resection in certain nonneoplastic diseases.     

Speichelgangkarzinome der Glandula submandibularis

BACKGROUND: Salivary duct carcinoma (SDC) is a rare adenocarcinoma of the salivary glands which usually occurs in the parotid gland (approx. 80%), but is also found in the submandibular gland (approx. 12%) and the minor salivary glands. Due to the low incidence of this tumour-particularly in terms of involvement of the submandibular and minor salivary glands-only limited clinical data is available. PATIENTS/METHOD: In a retrospective investigation, follow-ups of six patients with a SDC of the submandibular gland were analysed and the surgical measures evaluated for their efficiency. RESULTS: At the time of diagnosis, varying tumor stages were present (2xT1, 3xT2, 1xT1). Initial lymph node metastasis was observed in four (66.6%) of the six patients. In all patients, the submandibular gland was resected and neck dissection performed, in two cases (33,3%) this was followed by radiotherapy. Four patients developed a life-threatening local recurrence. Only one patient developed distant metastasis. Two thirds of the patients died due to tumor-related disease after an average of 35.5 months. CONCLUSION: The clinical course of patients with SDC of the submandibular gland exhibits a high (66.6%) rate of local recurrence, crucial for the following clinical course. The treatment of these patients, therefore, must include radical tumor resection as well as tissue resection with a wide margin.     

Significance of Unilateral Submandibular Gland Excision on Salivary Flow in Noncancer Patients

Objectives/Hypothesis: Normal salivary flow is important for maintaining good oral hygiene. Lack of normal flow predisposes to an increased incidence of dental caries and symptomatic xerostomia. The submandibular glands are responsible for 70% of resting salivary flow. Removal of the submandibular gland is most commonly performed for sialolithiasis, chronic sialoadenitis, or as part of a neck dissection. The effect of unilateral gland resection for benign disease on resting salivary flow has not been well examined in the literature. Study Design: Case controlled study involving patients who had undergone a unilateral submandibular gland resection matched with normal control subjects. Method: Stimulated and unstimulated salivary flow rates in surgical and control subjects were measured in a controlled setting. Results: Unstimulated salivary flow rates were 0.805 mL/min in the control group and 0.405 mL/min in the surgical group (P = .01). Stimulated salivary flow rates were not significantly different between the two groups (P > .05). Fifty-seven percent of patients in the surgical group and 14% in the control group had xerostomia (P < .05). Conclusion: Unilateral submandibular gland excision results in a decreased rate of resting salivary flow and an increase in subjective xerostomia.     

Salivary duct carcinoma of submandibular gland with trigeminal nerve invasion to intracranium

Salivary duct carcinoma is a rare and invasive malignant tumour with rapid distant metastasis and dismal prognosis. Clinically, perineural invasion of the salivary duct carcinoma is commonly noted. Here, we present a case of salivary duct carcinoma of submandibular gland origin with perineural invasion of the trigeminal nerve proximal to the intracranium, that was well demonstrated by a magnetic resonance image (MRI) and was consistent with the clinical presentation. This case received radical resection and radiotherapy with inclusion of the skull base within the field. There was no tumour recurrence and distant metastasis 24 months post-operatively.     

Congenital abnormalities of the submandibular duct.

Five newborns presented with cystic lesions of the floor of mouth. Four of these patients proved to have congenitally imperforate submandibular salivary gland ducts and the other newborn proved to have a duplication anomaly of the submandibular gland duct and gland. The patients with imperforate Wharton's ducts underwent marsupialization with or without ductoplasty and have been without evidence of recurrence for up to three years. The duplication anomaly of the submandibular gland duct responded to simple excision. The diagnosis of congenital anomalies of the submandibular gland and duct can be made on physical examination. Magnetic resonance imaging can be helpful in differentiating congenital imperforate submandibular duct and duplication anomalies of the ductal system. Treatment of the former consists of duct marsupialization in the floor of mouth with or without ductoplasty. Treatment of the duplicated ductal system may best be treated with excision. A failure in diagnosis and treatment may result in ranula formation or sialoadenitis requiring more extensive therapy.     

Adenocarcinoma of the salivary glands. The pathohistology and subclassification of 77 cases

Seventy-seven adenocarcinomas of the salivary glands recorded in the Salivary Gland Register between 1965 and 1984 were analysed and classified histopathologically. The following results were obtained: 1. 2% of all salivary gland tumours and 10% of all malignant epithelial salivary gland tumours were allotted to the group of adenocarcinomas. The age peak lies in the 7th to 8th decade. 60% occurred in women, 58.5% were localized to the parotid gland, 28.5% to the minor salivary glands (palate, lips, and cheek), 11.5% to the submandibular gland and only 1.5% to the sublingual gland. 2. Solid, tubular and papillary adenocarcinomas can be distinguished. Additional criteria are microcysts, mucus production and grade of differentiation. 3. The solid adenocarcinoma (13%) is predominantly localized in the parotid gland and characterized by a low differentiation, invasive growth and metastases. 4. 62.5% of tubular adenocarcinomas (52%) are localized in the parotid gland, 27.5% to the minor salivary glands and 10% to the submandibular gland. Most of the tumours are highly differentiated. A distinct mucus production is present in 40% of the cases. Microcysts are very frequent. 5. Papillary adenocarcinomas (28.5%) are localized in almost 50% of cases to the minor salivary glands, 45% to the parotid and only 5% to the submandibular gland. Microcysts and mucus production can be observed in 50% of the cases. 6.5% of the cases have a mixed tubular papillary structure. 6. In differential diagnosis, thyroid gland carcinomas and metastases of other adenocarcinomas must be distinguished, the former by negative result of the thyroglobulin reaction, and absent mucus production. 7. Adenocarcinomas arise from the salivary duct system. Solid or tubular adenocarcinomas imitate stages of the embryonal development of the salivary ducts.     

Large cell neuroendocrine carcinoma of the submandibular gland: Case report and literature review

Large cell neuroendocrine carcinoma (LCNEC) of the salivary gland is extremely rare. We report on a case of LCNEC in the submandibular gland. A 58-year-old male had a four-month history of an enlarging mass in his left submandibular region. He underwent lymph node resection and metastasis of LCNEC was suspected. Magnetic resonance imaging of the neck showed a solid submandibular gland tumor with marginal blurring. Positron-emission tomography and upper gastrointestinal endoscopy showed no evidence of malignancy other than in the left submandibular gland. He underwent left submandibular gland resection and left upper neck dissection. The final diagnosis was LCNEC of the submandibular gland; surgical margin was negative. Fourteen months later he is free of tumors. This is the first report of LCNEC of the submandibular gland. LCNEC of the salivary gland shows high-grade malignancy like that of the lung. According to past reports, two of four patients died despite multidisciplinary treatments. There are no standard treatments for LCNEC of the salivary glands. More studies are needed to define prognostic factors and establish therapeutic methods.     

Granular cell tumor -- a rare tumor lesion of submandibular gland origin

RATIONALE: Granular cell tumors are rare entities with manifestations in nearly all organ systems. Appearance in salivary glands is observed in singular cases. CASE REPORT: We report a 54 years old female patient with a painless submandibular tumor lesion. Using a submandibular approach the tumor was totally removed with the submandibular gland. Histologically a benign granular cell tumor was diagnosed. The immunohistological examination revealed positive for S-100 antigen and vimentin, negative for KL1 antigen. The clinical follow-up for about 3 years was without complications or tumor recidive. CONCLUSIONS: A differential diagnosis of a submandibular mass is the rare manifestation of a benign granular cell tumor. The neurogen origin can be proven immunohistologically by positive S-100 antigen detection. The complete surgical resection is the therapy of choice.     

Transoral removal of submandibular hilar calculi

INTRODUCTION: Sialolithiasis is the most common non-neoplastic salivary gland disease, accounting for 1.2% of the autoptic population. More than 80% of salivary calculi are located in the submandibular ductal system. Hilar calculi are usually removed by transcervical submandibular sialadenectomy. However, intra-oral removal of hilum submandibular calculi is an interesting alternative. INDICATIONS: The main criterion for intra-oral removal is the calculi palpability, knowing that calculi under 8mm of diameter are often treated by other techniques (sialendoscopy and lithotripsy). OPERATIVE PROCEDURE: We describe a conservative and gland-preserving transoral surgical technique for hilar submandibular calculi with postoperative sialendoscopic control. The different surgical steps are illustrated. DISCUSSION: Preservation of the submandibular gland has been attempted in the treatment of sialotithiasis by transoral resection of calculi from the hilum of the gland. This technique features a low morbidity and leads to a complete recovery of glandular function.     

Guidelines of the French Society of Otorhinolaryngology–Head and Neck Surgery (SFORL), part I: Primary treatment of pleomorphic adenoma

IntroductionThe authors present the guidelines of the French Society of Otorhinolaryngology–Head and Neck Surgery (SFORL) for the diagnosis and treatment of pleomorphic adenoma (PA) of the salivary glands.MethodA review of the literature was performed by a multidisciplinary task force. Guidelines were drafted based on the articles retrieved and the workgroup members’ individual experience. Guidelines were graded A, B, C or expert opinion by decreasing level of evidence.ResultsIn clinically suspected salivary gland PA, MRI should be performed, including head and neck lymph node levels. Fine needle aspiration cytology is particularly recommended for tumours difficult to characterise by MRI. Frozen section biopsy should be performed to confirm diagnosis and adapt the surgical procedure in case of intraoperative findings of malignancy. Complete resection of the parotid PA should be performed en bloc, including margins, when feasible according to tumour location, while respecting the facial nerve. Enucleation (resection only in contact with the tumour) is not recommended. For the accessory salivary and submandibular glands, complete en bloc resection should be performed.     

Clinicopathological study of salivary gland adenocarcinomas

A total of 27 cases of salivary gland adenocarcinomas were studied from clinicopathological view point. Adenocarcinomas of the salivary gland were microscopically subclassified into 3 groups according to Luna's classification: Salivary duct carcinomas histologically resembled the ductal carcinoma of the breast, displayed nuclear atypia and had poorer prognosis than the other subclasses of salivary gland adenocarcinomas. Terminal duct carcinomas lacked in nuclear atypia and displayed a variety of growth patterns, including papillary, cribriform, tubular, and solid. Some terminal duct carcinomas showed prominent mucin-production. Epithelial-myoepithelial carcinomas had clear cytoplasms and exuberant glycogen. In addition to the clinicopathological study, nuclear areas of the tumor cells were measured in each of the 27 salivary gland adenocarcinomas, and mean nuclear area (MMA) and standard deviation (SD) were calculated. The group with more than 50 microns 2 of MNA had poorer prognosis than the group with 50 microns 2 or less of MNA, and the group with more than 13 microns 2 of SD had poorer prognosis than the group with 13 microns 2 or less of SD. Finally, immunohistochemical study was performed against various markers including keratin, epithelial membrane antigen, lactoferrin, S-100 protein, CEA, etc., using the Avidin-biotin-peroxidase complex method. Lactoferrin was present in most of the salivary duct carcinomas, on the other hand, S-100 protein was detected in all of the five cases of the terminal duct carcinoma investigated. But immunohistochemical study is not especially useful in distinguishing subclasses of salivary gland adenocarcinomas or investigating the origin of tumor cells.     

Submandibular gland transfer: a new method of preventing radiation-induced xerostomia

OBJECTIVE: Radiation-induced xerostomia is a significant morbidity of radiation therapy in the management of patients with head and neck cancers. We have recently reported a method of transfer of one submandibular gland to the submental space in a small pilot series of eligible surgical patients. The submental space was shielded during postoperative radiation therapy. The transferred gland continued to function after the completion of radiation therapy and none of the patients developed xerostomia. The purpose of this article is to present the technique of submandibular gland transfer in detail and to evaluate the postoperative survival and function of the transferred submandibular glands. DESIGN: Prospective clinical trial. METHODS: The submandibular gland was transferred on eligible patients as part of their surgical intervention. The patients were followed clinically, with salivary flow and radioisotope studies. RESULTS: We performed the surgical transfer of the submandibular salivary gland in 24 of 25 patients placed on the protocol. All the glands survived transfer and functioned well postoperatively as demonstrated on the salivary flow and the radioisotope studies. The surgical transfer was relatively simple and added 45 minutes to the surgical procedure. There were no complications attributed to the submandibular gland transfer. CONCLUSIONS: We have successfully demonstrated that the submandibular gland can be surgically transferred to the submental space with its function preserved. The gland seems to continue functioning even after radiation therapy with the appropriate shielding. This surgical transfer procedure has the potential to change the way we currently manage patients with head and neck cancer.     

Extracorporeal Electromagnetic Shock-Wave Lithotripsy for Salivary Gland Stones

Sialoadenectomy for sialolithiasis is necessary when the stone cannot be removed through the salivary duct. In addition, extracorporeal shock-wave lithotripsy has recently become available for this purpose. The safety and efficacy of this method was assessed in 52 outpatients bearing stones with an average diameter of 6.76 mm in the submandibular or parotid gland. Anesthetics, sedatives, and analgesics were not required. Twenty-four of the 36 patients with submandibular gland calculi and all 16 with parotid sialolithiasis had complete stone disintegration or fragmentation of the calculi, with possible spontaneous clearance. Untoward effects were observed in 15 patients, namely localized skin petecchiae, transitory swelling of the gland, and self-limiting bleeding from the duct. No persistent damage of the salivary glands or adjacent structures was noted during a mean follow-up period of 10 months.     

The ductal stretching technique: an endoscopic-assisted technique for removal of submandibular stones

OBJECTIVE: The purpose of this study was to describe an innovative surgical technique for the removal of posterior and hilar stones of the submandibular salivary duct. METHODS: Between 1999 and 2005, 172 patients who had sialolithiasis of the submandibular duct were treated primarily by transoral incision and marsupialization of the duct and salivary gland. The ductal stretching technique involved endoscopic location of the stone, incision of the oral mucosa above the duct, isolation of the duct from the surrounding tissues, stretching of the duct, ductal incision above the calculus, sialolithotomy, and insertion of a drain. RESULTS: Forty-one patients with stones located in the posterior aspect of the duct were symptom-free and stone free after the procedure. One hundred and five patients with stones located in the hilum were treated with a success rate of 98%. Twenty-six patients with multiple stones in the hilar region were treated with a success rate of 81%. The overall success rate of the procedure was 96%. In 48 patients (28%), an additional undetected stone was diagnosed by endoscopy after the removal of the stone in the hilum. In 62 patients (36%), strictures were diagnosed endoscopically posterior to the stone. Lingual nerve paresthesia occurred in one patient, who recovered completely. CONCLUSION: The ductal stretching technique is recommended as the procedure of choice in cases with posterior and hilar stones more than 5 mm in diameter to avoid surgical removal of the salivary gland.     

Schwellungen der Glandulae submandibularis und parotis

Swelling of single or multiple major salivary glands can be caused by various local or systemic diseases. In differential diagnosis, congenital cystic or vascular malformations should be considered, as well as infectious or tumorous alterations. Salivary duct obstructions due to sialolithiasis or stenosis can cause salivary gland enlargement. Multiple systemic diseases can have manifestations in the parotid or submandibular glands. As therapy varies from cause to cause, knowledge of the different potential diagnoses is crucial.     

Submandibular salivary duct cyst mimicking an external laryngocele

The clinical and radiological differential diagnosis of cystic lesions of the submandibular region can be difficult. We report an unusual case of a submandibular salivary duct cyst mimicking an external laryngocele on presentation by appearing to expand on Valsalva manoeuvre, and where computed tomography (CT) scanning was unhelpful in reaching a diagnosis. We present the case, discuss the theories of pathogenesis, and review the literature on the differential diagnosis of cystic lesions in the submandibular region.     

Effect of initial treatment on disease outcome for patients with submandibular gland carcinoma

OBJECTIVE: To elucidate the effect on outcome of initial surgical enucleation with or without definitive surgical resection and radiation therapy for patients with submandibular gland carcinoma. DESIGN: Retrospective clinicopathological review. SETTING: Tertiary referral center. PATIENTS: Eighty-seven consecutive patients (mean follow-up, 8.7 years) with primary submandibular gland carcinoma. MAIN OUTCOME MEASURES: Review of proven cases of primary carcinomas of the submandibular gland treated at our institution during a 33-year period to determine the effect of the type of biopsy and subsequent treatment on locoregional disease control, disease-specific survival, and overall survival. RESULTS: There was no statistically significant difference in locoregional disease control, disease-specific survival, or overall survival between patients undergoing enucleation of the gland vs patients undergoing enucleation of the gland followed by definitive surgical resection before any radiation therapy. There were no locoregional recurrences among 28 patients treated with enucleation and radiation therapy, compared with 3 locoregional recurrences (7%) among 42 patients treated with enucleation followed by definitive surgical resection before any radiation therapy. Twenty-nine (69%) of 42 patients undergoing a second surgical procedure had evidence of residual carcinoma in the final surgical specimen. CONCLUSIONS: En bloc surgical resection followed by radiation therapy remains the standard treatment for patients with submandibular gland carcinoma. Patients without clinical and radiographic evidence of disease after enucleation may be adequately treated with subsequent radiation therapy. Definitive surgical resection remains the treatment of choice for patients with clinical or radiographic evidence of disease after enucleation of the gland.