Volume 137, Issue 2 p. 343-345
Clinical Techniques and Technology
Free Access

Transoral Excision of the Submandibular Gland

Stephen M. Weber MD, PhD

Stephen M. Weber MD, PhD

Department of Otolaryngology and Head and Neck Surgery, Oregon Health & Science University, Portland, OR

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Mark K. Wax MD

Corresponding Author

Mark K. Wax MD

Department of Otolaryngology and Head and Neck Surgery, Oregon Health & Science University, Portland, OR

Corresponding author: Mark K. Wax, MD, Department of Otolaryngology and Head and Neck Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail address: [email protected]Search for more papers by this author
Jason H. Kim MD

Jason H. Kim MD

Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA

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First published: 22 November 2016
Citations: 3

Submandibular gland excision is commonly performed for indications including neoplasm, chronic sialoadenitis, and sialolithiasis. Submandibular gland anatomy is complicated by the intimate association between its duct and the lingual nerve as well as the hypoglossal nerve that lies deep to the gland. Owing to this anatomic complexity, a wide cervical exposure has been advocated. However, this approach puts at risk the marginal mandibular nerve,1 which typically lies within the fascia of the submandibular gland. Further, the transcervical incision leaves the patient with an obvious cutaneous scar. We have successfully utilized transoral excision of the submandibular gland to manage chronic sialoadenitis, sialolithiasis, and benign salivary gland tumors.

METHOD

Following induction of general anesthesia, orotracheal intubation is performed. Gelpi retractors and a lip retractor are used to expose the floor of mouth, which is injected with 1 percent lidocaine with a 1:100,000 dilution of epinephrine. Cautery is then used to incise the floor of mouth mucosa from the Wharton duct anteriorly to the retromolar trigone posteriorly. A cuff of gingival mucosa is preserved to provide a surface for tension-free wound closure and to limit the risk of tethering of the tongue. The lingual nerve (Fig 1, black arrowhead) is identified. It is not necessary to completely skeletonize the lingual nerve because this maneuver can result in traction injury. Instead, the nerve is dissected free only from its attachments to the submandibular duct and gland. It is carefully identified and protected as it crosses from a posterior-superiorlateral path beneath the duct. The gland is then progressively bluntly dissected and delivered into the wound. At this point, the hypoglossal nerve is identified (Fig 1, white arrowhead) and preserved. The superficial portion of the gland, which lies laterally to the mylohyoid muscle, is delivered into the incision. External pressure is a critical factor in being able to deliver the gland into the wound and to provide sufficient exposure to successfully complete the procedure. Careful attention is paid to branches of the facial artery and vein at this point because they course in close relation to the superficial portion of the submandibular gland. The wound is closed with interrupted 4-0 chromic sutures in a tension-free fashion. No drains are placed. All patients receive prophylactic antibiotics effective against oral flora.

Details are in the caption following the image

(A) Following injection of local anesthetic with epinephrine, the floor of mouth is incised from the submandibular duct to the retromolar trigone. The lingual nerve is identified (black arrowhead). (B) The lingual nerve is freed bluntly from attachments to the gland. (C) The hypoglossal nerve (white arrowhead) is identified during blunt dissection as the gland is delivered into the wound. (D) All floor-of-mouth wounds healed without event.

DISCUSSION

In this report, we describe our technique of transoral resection of the submandibular gland. We have used this approach for management of chronic sialoadenitis (n = 3), sialolithiasis (n = 2), and benign salivary gland tumor (n = 2). In both cases of pleomorphic adenoma, there was no evidence of recurrence during 30 and 32 months of follow-up. In a single patient, transoral exposure was inadequate owing to scarring from prior subtotal gland removal at another institution and a small oral cavity, necessitating conversion to a transcervical approach. We have not experienced any permanent sequelae, but have encountered temporary abnormal tongue sensation (n = 3, 43%) that resolved within 2 months. We did not experience any alteration in tongue mobility or function. A single patient developed a floor-of-mouth infection that resolved with oral antibiotics.

Hong et al2 previously evaluated 31 patients treated with this surgical approach and found an 81 percent incidence of temporary abnormality in tongue sensation. The authors also noted temporary limitation of tongue movement in 68 percent of patients and a 10 percent incidence of scar contracture that permanently limited tongue mobility. An additional patient had a macroscopic residual salivary gland left behind at the time of surgery. Smith et al3 reported a similar technique in the plastic surgery literature, whereas Guerrissi et al4 described the addition of an endoscope-assisted method to improve exposure.

Overall, we experienced a lower rate of complications than that seen in prior reports. We have found several maneuvers to be critical in limiting postoperative complications. With regard to incision planning, a cuff of gingival mucosa is preserved to allow tension-free wound closure and to prevent tethering of the tongue. Further, we have limited the amount of skeletonization of the lingual nerve to that required to free it from the gland, limiting stretch injury likely responsible for temporary abnormal tongue sensation. Although Guerrissi et al4 provided an additional method of exposure, we have found that the transoral approach has provided adequate exposure of the floor-of-mouth anatomy without the need for endoscopic assistance. We encountered a single patient who required conversion to a transcervical approach, but it is unlikely that endoscopic assistance would have prevented this.

Although we describe a lower incidence of temporary abnormal tongue sensation, the risk of this temporary complication must be discussed at length with the patient. Further, the risk of marginal mandibular nerve injury and creation of a cutaneous scar must be discussed when the option of traditional transcervical approach is presented. Certainly, this approach cannot be applied to all patients with submandibular pathology. Patients with malignant salivary gland tumors or benign tumors with significant extension into the neck will likely require transcervical approach. Further, patients with trismus, mandibular hypoplasia, or any other limitation to mouth-opening or floor-of-mouth exposure likely will require a traditional transcervical approach.

CONCLUSION

In the properly selected patient, transoral resection represents an effective approach to the submandibular gland while sparing patients from a cervical scar. Our experience suggests that this approach is indicated for management of chronic sialoadenitis, sialolithiasis, and benign salivary gland tumors.

FINANCIAL DISCLOSURE

None.