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

Drainless resection of the submandibular gland with facial vessel preservation: A comparative study

OBJECTIVE

Resection of the submandibular gland (SMG) is a common surgery and many surgeons leave a drainage system in the surgical field. However, surgical drain may increase risk of complication and related prolonged hospitalization time. The purpose of this study was to investigate the safety of SMG resection without any surgical drainage system.

METHODS

This retrospective trial on SMG surgery was conducted between 2016 and 2019. Patients were assigned into one of two main groups: surgical drain (+) (n=20) and surgical drain (-) (n=17). All surgical procedures were done via a standardized surgical technique. Facial vessels were dissected and only glandular branches were ligated. Also, non-identification method was applied for marginal mandibular nerve (MMN) protecting. In surgical drain (-) group, before the wound closure, oxidized regenerated cellulose (ORC) was placed in the surgical field. Moreover, a closed suction drain was inserted in surgical drain (+) group.

RESULTS

A total of 37 SMG resections were performed: 15 patients had sialolithiasis, 14 patients had pleomorphic adenoma and 8 patients had chronic sialadenitis. There were 20 women (54%) and 17 men (46%), with an age range of 23-70 years. No major complications were observed in surgical drain (-) group. There were two cases with minor complications. One patient (5.8%) occurred transient paralysis of the MMN. Other patient developed seroma and it was easily managed with repeated punctures. ORC related allergic reaction or adverse incident were not detected in any of the patients. On the other hand, in surgical drain (+) group, 2 patients (10%) developed a hematoma on the first postoperative day and local wound infection was detected in 4 patients (20%). We found that the surgical drain usage was related to prolonged hospitalization, worse wound healing and problems with scarring.

CONCLUSION

Our findings provide evidence for the safe drainless resection of the SMG using ORC. It may be possible to prevent all of these undesirable conditions by a surgery which performed without drain insertion.

Noninvasive treatment for chronic sialadenitis: Case report

This reporter expresses a patient with a history of tender neck swelling. After clinical and graphical examinations, the patient was diagnosed with submandibular sialolithiasis. Instead of invasive removal of the gland, a more conservative treatment was used. Eventually, after a 1-year-long follow-up, the patient's conditions were found to be acceptable.

Removal of stones from the superficial lobe of the submandibular gland (SMG) via an intraoral endoscopy-assisted sialolithotomy

OBJECTIVES

Sialolithiasis is the most common cause of chronic sialadenitis of the submandibular gland (SMG). Symptomatic superficial lobe stones are often treated by submandibulectomy. A gland preserving operation allows for transoral stone removal through endoscopically assisted sialolithotomy. Herein, we provide clinical and sonographical follow-up data in patients who underwent sialolithotomy under general anesthesia.

MATERIALS AND METHODS

Sixty patients treated at the Department of Oral and Maxillofacial Surgery at Düsseldorf University Hospital for superficial lobe sialolithiasis of SMG were included in this study. All received transoral sialolithotomy under general anesthesia. Follow-up was conducted via standardized patient questionnaires, clinical examination, and B-mode and color Doppler sonography.

RESULTS

Mean patient age was 48.9 years. 56.6% of right and 43.4% of left SMG were affected. Mean follow-up was 45 months. Fifty-five of 59 detected stones could be removed. Mean operation time was 71 min. 3.3% of patients reported recurrent episodes of postoperative pain and 10% felt recurrent episodes of gland swelling. Persistent postoperative lingual nerve hypesthesia was described in one patient. No facial nerve damages occurred. Salivary flow rates remained reduced in most of the affected glands upon stone removal. Sonographical follow-up data of the previously affected SMG after intraoral endoscopy-assisted sialolithotomy showed a regular gland size in 70.8% of cases, a parenchyma free of inflammation in 93.8%, and without signs of fibrosis in 72.9% of cases. 68.7% of patients showed a regular structure of Wharton's duct at time of follow-up. In total, 89.6% of patients were diagnosed stone-free within both glands on follow-up. No case required subsequent submandibulectomy.

CONCLUSIONS

Sialolithotomy of Wharton's duct for removal of stones from the SMG's superficial lobe is a promising alternative to submandibulectomy.

CLINICAL RELEVANCE

Reduction of postoperative morbidity through endoscopically assisted sialolithotomy for removal of superficial lobe stones from SMG.

TRIAL REGISTRATION

Ethics Committee of Heinrich-Heine-University Düsseldorf (no. 5586).

A sialoadenectomy is associated with an increased risk of coronary heart disease: A three-year follow-up study

Little is known regarding the long-term adverse effects of a sialoadenectomy. The purpose of this study was to estimate the risk of coronary heart disease (CHD) among patients receiving a sialoadenectomy procedure by utilizing a cohort study based on a population-based database in Taiwan. This study retrieved data of the study sample from the Longitudinal Health Insurance Database 2005. This retrospective cohort study included 608 patients who underwent a sialoadenectomy and 1824 propensity score-matched comparison patients. We individually tracked each sampled patient for a 3-year period from their index date to discriminate those who subsequently received a diagnosis of CHD during the follow-up period. We found that respective incidence rates of CHD during the 3-year follow-up period were 3.87 (95% confidence interval (CI): 3.01–4.91) and 1.79 (95% CI: 1.45–2.18) per 100 person-years for patients who did and those who did not undergo a sialoadenectomy. The stratified Cox proportional analysis revealed that the hazard ratio of CHD during the 3-year follow-up period was 2.43 (95% CI: 1.77–3.33) than comparison patients. This study demonstrates an association between sialoadenectomy and CHD.

Operative technique for benign submandibular gland mass without identifying the mandibular branch of the facial nerve

OBJECTIVE

The marginal mandibular branch of the facial nerve must be protected during surgery for benign diseases of submandibular gland. Methods for protecting the marginal mandibular branch include the nerve identification method and the non-identification method.

METHODS

We performed submandibular gland surgery in 138 patients with benign submandibular gland diseases using the non-identification method to preserve the marginal mandibular branch. In brief, the submandibular gland capsule is incised at the inferior border of the gland and detached along the gland parenchyma. The nerve is protected by this procedure without the need for identification.

RESULTS

Among 138 patients who underwent this surgical procedure, only 7 patients developed transient paralysis of the lower lip.

CONCLUSION

This method of resecting the submandibular gland without identifying the marginal mandibular branch is an effective procedure associated with a low incidence of transient paralysis. Moreover, no patient developed paralysis due to procedural errors.

Transoral submandibulotomy for deep hilar submandibular gland sialolithiasis

OBJECTIVES/HYPOTHESIS

To assess the long-term results after transoral submandibulotomy for stones located in the deep hilar and intraparenchymal submandibular region.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Retrospective evaluation including all patients treated with transoral submandibulotomy for sialolithiasis at a tertiary referral center.

RESULTS

Complete stone removal at the first transoral surgical treatment was achieved in 185 of 234 patients (79.1%). One hundred seventy-five of the 234 patients were followed up for a mean of 31.2 ( ± 20.5) months. During the follow-up period, 140 of the 175 patients (80.0%) became symptom free after one operation. In patients with residual symptoms, no further treatment was needed in 12 patients (6.9%) due to the mildness of the symptoms; 23 patients (13.1%) received further therapy, which was successful in 15 cases. Submandibulectomy only had to be performed in 3.4% of the patients with follow-up (6/175). In a questionnaire survey, 91.4% of the patients stated that they would be prepared to have the same operation again.

CONCLUSIONS

These findings show that transoral removal of submandibular sialoliths located in the deep hilum or adjacent intraglandular parenchyma is an effective treatment that can be assisted by additional measures. The techniques described show high success rates, good long-term results, low complication rates, and they avoided the need for submandibulectomy in >95% of cases.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2038-2044, 2017.

A Technique for Preoperative Identification of the Facial Nerve Mandibular Branch Using a Nerve Stimulator

We established the method of preoperative identification to facial nerve marginal mandibular branch (FNMB) identification using a nerve stimulator with bipolar probe for upper-neck surgery. The bipolar electrode is placed on the region while patients were awake; the patient should be in the same position and posture as during the surgery, with the neck skin stretched. A nerve course is confirmed by observing the movement of the lower lip. In this study, 5 upper-neck surgeries were conducted. Preoperative analysis revealed that 4 of the 5 cases had 2 branches of FNMB, and 1 with 3 branches. All FNMB immediately confirmed preoperatively were identified during surgery. We performed this method in much surgery including the surgery of the upper neck. It was easy to identify the facial nerve by this method and came to be able to do it precisely, and an operative time was shortened. We concluded that the preoperative FNMB identification using a nerve stimulator is most useful and benefit for upper-neck surgery patients and lead to avoid lower lip paralysis.

Determination of a safety zone for transbuccal trocar placement: an anatomical study

The identification of a safe and accurate technique for facial incisions for transbuccal approaches to the mandibular angle fractures remains a challenge. An alternative method of safely and accurately placing the buccal skin incision is described in this cadaveric study. Thirty-two dissections were performed on 16 bilateral embalmed adult cadaveric heads. In order to identify a safety zone for transbuccal trocar placement, a triangle shaped zone created by three lines was determined. The branches of the facial nerve in this zone were reflected by sharp and blunt dissections. Of 32 sides, marginal mandibular branch was encountered in 1 and marginal mandibular branch and buccal branch of the facial nerve were found in 2 of the predetermined triangle. In 29 of 32 specimens, the marginal mandibular branch was encountered out of the triangle and deep to the platysma muscles. The triangle determined in the present anatomosurgical study presents an easy identifiable and safe zone for trocar placement.

Minimally invasive video-assisted submandibular sialoadenectomy: a preliminary report

Open-field sialoadenectomy is the first-choice treatment for submandibular disease. Conventional surgery is based on the transcervical approach. The present study aims to demonstrate the feasibility of a minimally invasive video-assisted sialoadenectomy and to describe a new technique to perform it. A 52-year-old man affected by chronic sialoadenitis underwent minimally invasive video-assisted sialoadenectomy under general anesthesia. The ultrasound scanning of the submandibular gland showed a 6.5-cm hypertrophic gland with dilatated intraglandular ducts and a 2-cm long intraglandular sialolith. After surgery, no static or dynamic nerve deficiencies were detected, but slight temporary deficiency of the marginalis mandibulae nerve recovered in 15 days. Cosmetic results satisfied the patient. Minimally invasive video-assisted submandibular sialoadenectomy can be a feasible and safe procedure, which could be a valid choice to conventional surgery if performed on selected cases. More experience must be collected to analyze the cost-effectiveness.

Pleomorphic adenoma of the submandibular gland: an evolving change in practice following review of a personal case series

We reviewed patients with submandibular gland pleomorphic adenoma treated at a tertiary referral centre in the United Kingdom (1988-2004). Thirty-seven patients were identified, 32 newly diagnosed cases and 5 cases of recurrent disease previously treated elsewhere. The exact pre-operative diagnosis was "unknown" in 76% of the new cases. All cases were surgically excised (41% with extracapsular gland excision and 59% by selective level Ib, IIa and III neck dissection). Temporary marginal mandibular nerve neuropraxia was documented in 25% of cases. All 32 new cases remain clinically tumour free at the time of writing. In patients with recurrent disease, complete microscopic tumour clearance was achieved in three of the five cases, however all remain clinically tumour free. Pleomorphic adenomas of the submandibular gland are uncommon, with good prognosis following complete tumour excision. Recurrent tumours, however, are frequently multi-focal and difficult to excise completely. The adequacy of primary surgery is crucial and supports an approach for a more radical excision primarily by a selective level lb, IIa and III neck dissection; ensuring complete disease clearance for pleomorphic adenoma, avoiding the risks of tumour spillage associated with a limited excision and tumour handling; and removing the primary echelon of lymph nodes at risk of metastasis if the pathology turns out to be malignant.

Submandibular Gland Excision: 15 Years of Experience

PURPOSE

The surgical management of submandibular gland diseases has always been a challenge because it carries a considerable risk of nerve injury. The aim of this study was to review a single institution's experience of a nonselected case series of submandibular gland excision over 15 years.

MATERIALS AND METHODS

We retrospectively analyzed 258 unselected submandibular excisions of a tertiary university center for the histopathologic diagnosis and postoperative morbidity; 119 patients (46%) with sialolithiasis, 88 patients (34%) with sialadenitis, and 51 patients (20%) with submandibular tumors were operated.

RESULTS

We found a high rate of malignant tumors (42%) in the group of submandibular gland tumors. A low rate of transient palsies of the mandibular branch of the facial nerve (9%) and lingual nerve (2%) was observed. One patient developed a permanent paresis of the mandibular branch (<1%).

CONCLUSION

Our large series has shown that standardized submandibular sialadenectomy is a safe operation with a low rate of complications. Malignant disease is frequent in tumors of the submandibular gland.

Anatomosurgical study of the marginal mandibular branch of the facial nerve for submandibular surgical approach

The purpose of this study was to estimate the distance from the mandibular marginal branch of the facial nerve to the inferior margin of the mandible in order to determine the best and safest location to approach the posterior mandibular region. Forty-five hemi-faces of 27 Brazilian adult cadavers were dissected and the distance between the mandibular marginal branch and the inferior margin of the mandible was measured. The number of marginal branches and anastomoses with other branches of the facial nerve was also recorded. The evaluation of the anatomic pieces showed 1 to 3 branches of the marginal mandibular branch, anastomoses with the buccal and cervical branches of the facial nerve and distances between 1.3 cm to +1.2 cm from the inferior margin of the mandible. In 57.7% of the cases, the nerve passed superiorly and along the length of the inferior margin of the mandible. Based on the findings of the present anatomosurgical study, it may be recommended an incision 3 cm below the inferior margin of the mandible associated to a careful dissection in planes and flap retraction. This is expected to reduce the risk of neuropraxia of the marginal mandibular nerve making the submandibular incision a safe approach.

Modified Radical Neck Dissection for Differentiated Thyroid Cancer: Operative Technique

Our standard surgical approach to patients with papillary thyroid cancer is subtotal thyroidectomy with modified radical neck dissection (MRND) on the affected side. MRND preserves the jugular vein, the sternocleidomastoid muscle, and the accessory nerve, effectively conserving function and cosmesis. Knowledge of the anatomy of the neck, precise staging, prognostic evaluation, and experience are needed for a surgeon to perform MRND. Radical neck dissection should not be performed unless the tumor invades the jugular vein and sternocleidomastoid muscle. Berry picking is not indicated for patients with thyroid cancer. The skin incision used is an extended collar incision. If lymph node metastasis is present at the upper bifurcation of the carotid artery, a modified MacFee incision is used. Taping of the carotid artery or sternocleidomastoid muscle is avoided unless the tumor invades these tissues. MRND is a safe procedure when performed by skilled, experienced surgeons.

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.

Nerve paralysis after surgery in the submandibular triangle: review of University of Tokyo Hospital experience

BACKGROUND

We assessed the incidence of neural complications in submandibular surgery in relation to the type of surgery, experience of the surgeon, and other factors.

METHODS

We retrospectively reviewed the records of 133 patients who underwent excision of the submandibular triangle components at the University of Tokyo Hospital during the last 19 years.

RESULTS

The most frequent complication was mandibular branch paralysis. Excluding 12 patients with malignant tumors, facial weakness was present postoperatively in 29.8% (37) or 124 resections. All palsies subsequently resolved. The paralysis was more frequent when nerve identification was performed than when it was not.

CONCLUSIONS

The cardinal factors in minimizing incidence of nerve damage are an understanding of the anatomy of the nerves, low and generous skin incision, awareness of orientation in the surgical planes, avoidance of the use of metal retractors, and avoidance of elaborate identification of the nerve.