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cta Otorrinolaringol Esp. 2012;63(1):42---46

www.elsevier.es/otorrino

RIGINAL ARTICLE

urgical Complications of Submandibular Gland Excision�

onica Hernando,a,∗ Rosa Maria Echarri,a Muhammad Taha,a Luz Martin-Fragueiro,b

na Hernando,c Guillermo Plaza Mayora

Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Madrid, SpainServicio de Anatomía Patológica, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Madrid, SpainServicio de Neurorradiología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Madrid, Spain

eceived 28 February 2011; accepted 11 August 2011

KEYWORDSSubmandibular glandexcision;Salivary glandneoplasm;Marginal facial nerveparalysis

AbstractIntroduction and objectives: Submandibular gland excision is the treatment of choice in chronicpathology resistant to medical treatments or in oncological cases. The aim of this study was toanalyse its current postoperative complications.Materials and methods: Retrospective study on submandibular gland excisions performed atour University Hospital between 2004 and 2010.Results: A total of 29 submandibular gland excisions were performed: 44.8% (13) for chronicsialadenitis, 37.9% (11) for salivary gland neoplasm and 17.2% (5) for adjacent tumours. Medianlength of hospital stay was 2 days. Complications were more common after gland excision dueto inflammatory causes. There were only 2 cases of paralysis of the marginal facial nerve branch(6.8%); 1 was due to neoplastic pathology and 1 from inflammatory pathology.Conclusion: Despite marginal facial nerve paresis being one of the most relevant issues aftersubmandibular gland excision, this type of surgery is a safe technique in our experience.© 2011 Elsevier España, S.L. All rights reserved.

PALABRAS CLAVESubmaxilectomía;Neoplasia salivar;Paresia marginal

Complicaciones quirúrgicas de la cirugía submaxilar

ResumenIntroducción: La submaxilectomía es el tratamiento de elección en afección crónica resistentea tratamiento médico o en sospechas tumorales. El objetivo de este estudio es evaluar la

morbilidad actual de la submaxilectomía.

retrospectivo sobre las submaxilectomías realizadas en un hospital

Material y método: Estudio universitario entre 2004 y 2010.Resultados: Se realizaron 29 submaxilectomías, 44,8% (13) por sialoadenitis crónica, 37,9% (11)por tumores submaxilares y en 17,2% (5) casos por tumores adyacentes a la glándula. El tiempomedio de ingreso posquirúrgico fue de dos días. Las complicaciones fueron más numerosas en

� Please cite this article as: Hernando M, et al. Complicaciones quirúrgicas de la cirugía submaxilar. Acta Otorrinolaringolsp. 2012;63:42---6.∗ Corresponding author.

E-mail address: monicahernandoc@hotmail.com (M. Hernando).

173-5735/$ – see front matter © 2011 Elsevier España, S.L. All rights reserved.

Surgical Complications of Submandibular Gland Excision 43

los casos de submaxilectomía por etiología inflamatoria. Se evidenciaron dos casos (6,8%) deparesia marginal leve, una por etiología tumoral y otra por etiología inflamatoria.Conclusión: A pesar de que la parálisis marginal es una de las complicaciones más relevantesde esta cirugía, en nuestra experiencia la submaxilectomía es una técnica segura.© 2011 Elsevier España, S.L. Todos los derechos reservados.

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Introduction

The removal of the submandibular gland has been a well-established surgical procedure for over 40 years,1 but it stillremains a challenge for surgeons due to the risk of damagingthe marginal branch of the facial nerve and the hypoglos-sal and lingual nerves.1,2 Surgical resection is typically thetreatment of choice in the submandibular gland, both whenaffected by a tumour and by a treatment-resistant, chronicmedical condition.3 However, there has been a decline in itsuse during recent years.

Tumoral involvement of the salivary gland is rare,accounting for 3% of all head and neck tumours,2---4 althoughthe incidence of these tumours is increasing with respect toepithelial lesions of the upper aerodigestive tract. Moreover,while in the parotid gland only 1 in 6 tumours is malignant, inthe submandibular gland this percentage is higher, reachingover one third of cases.2

Modern imaging techniques are being introduced in casesof sialolithiasis or inflammatory diseases that enable endo-scopic diagnosis and treatment of salivary lithiasis with alow number of complications.5---8 However, it still remainsunclear whether the recurrence rates and complications areequivalent to those of conventional excision of the gland.9

The objective of this study was to assess the currentmorbidity of submaxillectomy, by reviewing a number of sub-maxillectomies performed in our area over the past 5 years,with an emphasis on surgical complications.

Materials and Methods

We retrospectively reviewed the records of all patientswho had undergone submaxillectomy, due to both benignand malignant aetiology, at a university hospital during theperiod between 2004 and 2010, with a minimum follow-upof 6 months after surgery.

During this period, our hospital performed 36 sub-maxillectomies on 35 patients: 36% (13) due to chronicsialadenitis, 30.5% (11) due to submandibular tumours and33% (12) due to tumours adjacent to the submandibulargland.

The group of tumours adjacent to the submandibulargland does not include those submaxillectomies performedfor carcinomas in common surgical protocols (7 submaxillec-tomies performed on 2 carcinomas of the mouth floor andon 5 lip carcinomas). The series does include the submaxil-lectomies performed on a deferred basis on 3 patients withtongue carcinoma from repeated submaxillaritis related to

scarring/stenosis of the Wharton duct.

Complying with these criteria, we finally reviewed themedical records for 29 submaxillectomies in 29 patients:44.8% (13) due to chronic sialadenitis, 37.9% (11) due to

43cm

ubmandibular tumours and 17.2% (5) due to tumours adja-ent to the submandibular gland or a chronic submandibularondition clearly related to previous cancer surgery (stenosisy scarring).

We reviewed all records available, including surgical pro-ocols, anatomical pathology reports and notes on evolutionuring hospital admission and consultation during review.

We analysed data from the clinical histories (age, gen-er and time course of the symptoms before arrival at ourlinic), additional tests (fine needle aspiration [FNA] report,ltrasound/computed tomography [CT] and their correla-ion with the final anatomopathological diagnosis), as wells patient outcomes (mean time of admission, immediatewithin 1 month] and late [persistence at 6 months afterurgery] postoperative complications).

The submaxillectomy technique used was the habitual,1---3

y trachelectomy more than 2 cm away from the mandibu-ar branch (Risdon incision), dissection of the capsule, facialrtery and vein ligation and Wharton duct ligation, pre-erving the lingual nerve. We did not use facial nerveonitoring on a regular basis.For surgical complications we can include: postoperative

aemorrhage/haematoma, wound necrosis or dehiscence,ever or wound infection, sialocele, paresis or paralysis ofhe marginal, lingual or hypoglossal nerves, both immedi-te (within 1 month) and permanent (persistent at 6 monthsfter surgery). Marginal nerve function was assessed pre-peratively to confirm its integrity and was also evaluatedostoperatively, first at the hospital, 24 h after the opera-ion, and then in follow-up controls for 6 months.

esults

aking into account the inclusion criteria already men-ioned, a total of 29 submaxillectomies were performed on9 patients in the period between April 2004 and May 2010.n 13 patients (44.8%), submaxillectomy was performed dueo inflammatory and/or lithiasic disease unresponsive toonventional medical treatment. In the remaining 16 cases55.2%), it was performed in relation to tumour involvement.ubmaxillectomies due to tumours were performed in 68.7%11/16) of cases due to tumours of salivary origin, and in1.25% (5/16) due to tumours in the ENT area or due toases of non-salivary submaxillaritis derived from Whartonuct scarring/stenosis in patients operated on for tonguearcinoma.

Of the 13 submaxillectomies indicated by salivary inflam-atory condition, 54% (7/13) were on the right side and

6% (6/13) on the left side. The mean age of patients was8 years, ranging from 21 to 60 years. It was much moreommon in men, with a male:female ratio of 12:1. Theean evolution time of the condition before reaching ENT

44

Table 1 Final Anatomical Pathology of Samples From Sub-maxillectomies of Tumoral Aetiology.

Submaxillectomies of TumoralAetiology (16 Cases)

Benign salivary tumours Pleomorphic adenomas 6(37.5%)Warthin’s tumour 1 (6.2%)

Malignant salivary tumours MALT lymphoma 1 (6.2%)Cystic adenoid carcinoma 2(12.5%)Acinar cell carcinoma 1 (6.2%)

Non-salivary tumours Cervical Schwannoma 1(6.2%)Tongue carcinoma 3 (18.7%)Lipoma/lymphadenopathy 1

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onsultation was 20 months, ranging from 1 month to 5ears. FNA was performed in 23% (3/13) of cases, alliagnosed with sialadenitis and consistent with the finalistopathological diagnosis of the surgical specimen. Imag-ng tests were performed in 100% of patients: in 11 cases85%) by ultrasound, of which there was a positive cor-elation with the final anatomy of the specimen in 90%10/11) of cases; and in 5 cases (38%), the tests wereupplemented by CT scans, all of them compatible withialadenitis/sialolithiasis, with full concordance with thenal anatomy. The mean length of hospital admission was

ess than 2 days (1.8), with a range between 1 and 4ays. In 15% (2/13) of the submaxillectomies performed,e observed mild marginal paresis during the postopera-

ive period (after 24 h, during the first hospital control),lthough only 1 of them was maintained beyond 6 postopera-ive months. There was no evidence of paresis or paralysis ofhe hypoglossal nerve or the lingual nerve. As for the rest ofhe immediate postoperative complications, in 31% (4/13) ofhe submaxillectomies performed we observed infections inhe surgical field, which were treated with antibiotics; thereas seroma in 15% (2/13); 1 of the cases underwent 2 sub-

equent surgical revisions due to persistent infection (15%,/13); and there were no problems with suture dehiscencexcept in those cases of postoperative infection mentionedreviously (31%).

Of the 11 submaxillectomies caused by salivary tumours,6% (4/11) were malignant and 64% (7/11) were benignTable 1). Regarding lesion laterality, the interventions tooklace on the right side in 64% (7/11) of cases and on theeft side in 36% (4/11) of cases. The mean patient ageas 47 years, ranging from 10 to 81 years. Women suf-

ered more than twice as many cases as men (73% and7%, respectively). The mean evolution time of the tumourefore reaching ENT consultation was 25 months, rangingrom 1 month to 10 years. FNA was performed in 100% ofhe submandibular tumours, with concordance between FNAiagnosis regarding the specific type of tumour (pleomorphicdenoma, Warthin’s tumour, etc.) and the final histopatho-

ogical diagnosis of the surgical specimen in 86% of benignumours (6/7) and in 75% of malignant tumours (3/4). Imag-ng tests were performed in 100% of patients with salivary

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M. Hernando et al.

umours; for each of these results, the guidance offered byhe radiologist was contrasted with the particular type ofumour (Warthin’s tumour, pleomorphic adenoma, etc.) andhe final pathological anatomy. Ultrasound was performedn 54.5% (6 cases), of which there was a positive correla-ion between the radiology report and the final anatomyn only 33.3% (2/6). CT scans were performed in 63% (7ases), of which there was a positive correlation betweenhe radiology report and the final anatomy in 28.6% (2/7).he mean hospital stay was less than 2 days (1.7), with aange between 1 and 3 days. One slight case of facial pare-is was observed during the postoperative period in 1 of theubmaxillectomies performed to remove a benign tumourat 24 h, during the first hospital control), which persistedt 6 postoperative months. There was no evidence of paresisr paralysis of the hypoglossal nerve or the lingual nerve. Asor the rest of the immediate postoperative complications,ransient seromas were evident in 2 cases (18%), which werereated by repeated puncture on an outpatient basis withouturther complications. In 1 case (9%), there was an intra-ermal suture breakage during removal. No complicationsuch as necrosis or surgical wound dehiscence, postopera-ive bleeding, fever or superinfection of the wound werevident in this patient group.

The group of submaxillectomies performed due to non-alivary ENT tumours included 5 cases. Of these, 3 wereperated due to tongue carcinoma and the submandibularland contralateral to the operated side developed repeatubmaxillaritis clearly related to residual scarring at theevel of the Wharton duct during the first year after surgery.n all 3 cases, a CT scan was performed, with a final diag-osis of chronic submaxillaritis clearly correlated with thenal anatomy. In the 2 other cases included in this group1 schwannoma and 1 lipoma), submaxillectomy was per-ormed because the FNA report was doubtful and did not ruleut malignancy despite the fact that the radiology reportas suggestive of benign involvement. There were no casesf facial paresis of the hypoglossal nerve or the lingualerve. One patient suffered haemorrhage, which requiredurgical revision.

iscussion

lassically, submaxillectomy is a surgical technique per-ormed for the treatment of tumours or obstructiveonditions of the submandibular gland,1,2 especially inhe case of hilar-parenchymal obstructions not suscep-ible to sialendoscopy.Although submaxillectomy is aelatively standardised surgical procedure, there are stillomplications frequently published by different groups.hese complications include: nerve paralysis or paresis,esthetic sequelae, haematoma, salivary fistulas or sialoce-es, wound infections, hypertrophic scars and inflammationsaused by residual lithiasis in the salivary duct.9---21

In our series, over one third of the submaxillectomiesere still performed due to inflammatory condition, figures

imilar to those in the literature.9 Moreover, in our experi-

resent figures of infectious complications higher than thoseeported by other groups (8% by Smith and Christie et al.).e consider that this may be related to the facts that our

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Surgical Complications of Submandibular Gland Excision

centre covers an area with a depressed socioeconomic level,patients with inflammatory disease take longer time to con-sult their physicians, their tissues are in a worse conditiondue to the high number of past infections when performingsurgery and, finally, therapeutic compliance with postop-erative medication is not as regulated as it should be. Inany case, we keep this information in mind when obtaininginformed consent from our patients.

For many surgeons, there is an impression that sub-maxillectomy is associated with significant neurologicalcomplications relatively frequently. Of these neurologicalcomplications,9---21 the most common is transient or perma-nent paresis of the marginal nerve (the transient type beingdescribed in up to 36% of cases16 and the permanent inup to 12% of cases13). Temporary or permanent paresis ofthe hypoglossal nerve is more rare (2%---5%),12,14,17 as aretemporary or permanent lingual nerve injuries (2%---5%).9---19

Similarly to other authors, definitive marginal paresis wasvery rare in our series (6.8%), and the only evidenced casesin this series were not complete cases, but rather mildmarginal paresis (in terms of degree of impairment of lowerlip mobility). There were no lesions of the hypoglossal nerveor the lingual nerve.

There are many methods to reduce the risk of marginalnerve paralysis. Shaheen16 defined 3 manoeuvres to min-imise nerve damage:

1. A low approach with ‘‘non-identification’’ of the glandat the level of the hyoid bone, in which no attempt ismade to identify the marginal branch.

2. A clear identification and, therefore, protection of themarginal nerve at the level at which it leaves the parotidtail.

3. A division of the facial vessels in a low cervical areaand traction of the upper ends, thus retracting the nerveupwards and removing it from the surgical site.

All of these methods to minimise the risk of nerve dam-age are appropriate and direct visualisation of the nerve alsoprovides important guidance for surgeons in training. How-ever, like other authors,18 we believe that faced with equalresults regarding nerve integrity, the most useful manoeu-vres and those which we perform in our usual techniqueare: placing the head of the patient in neck hyperexten-sion to improve visualisation, making an incision more than2 cm away from the mandibular branch to avoid its path (in40% of cases, the nerve passes up to 1 cm below it22), andprotecting the nerve when raising the fascia covering it.

When using the technique of nerve ‘‘non-identification’’,we must take into account that the traction on the uppersurgical margin to expose the gland must be done deli-cately to avoid damaging the marginal nerve. We must becareful to avoid an inappropriate use of electric scalpelsin that area, and sectioning cervical nerve branches thatprovide function to the platysma should also be avoidedwhenever possible. In addition, we should attempt to enablea proper confrontation of the sectioned platysma muscleto avoid or at least minimise the duration of the tempo-

rary weakness of the lower lip that may stem from thesecauses. In fact, faced with what seems like a slight marginalparesis maintained over time, we believe that the perfor-mance of an EMG should be considered, so as to rule out the

45

nvolvement of marginal nerve function. As in 1 of our casesf mild marginal paresis was maintained for over 6 months,he patient refused to complete the proposed study; con-equently, we were unable to rule out the possibility thathe weakness in lower lip mobility was not due to otherauses.Intraoral resection of the submandibular gland hasecently been proposed to reduce the neurological sequelaef submaxillectomy. The small number of patients treatedeans that we cannot reach a clear conclusion on its validity

s an alternative to the traditional approach.23---27

Following the literature,28 at present, despite the facthat sialendoscopy6 or lithotripsy5 are techniques seekingo offer a suitable alternative to submaxillectomy in thereatment of symptomatic lithiasic sialadenitis, there istill a role for sialoadenectomy as a treatment for obstruc-ive disease. This is especially true in patients with aistory of multiple balloon dilations of ductal stenosis viandoscopy or in recurrences of those stenosis, various unilat-ral large stones or bilateral intraparenchymal stones withecurrent symptomatic sialadenitis, inability to remove ailar-parenchymal lithiasis with transoral or transcervicalemoval techniques, persistent and symptomatic cases ofialadenitis in patients with Sjögren’s syndrome who do notespond to systemic treatment or to local endoscopic wash-ng with steroids, and persistent symptomatic sialadenitis inrradiated patients.

Consequently, given that submaxillectomy remains theost commonly used technique at the end of most algo-

ithms for the treatment of inflammatory disease and in aegulated manner for the treatment of cancer, we believehat this technique is sufficiently relevant for the ENT spe-ialty training program to contemplate a minimum numberf submaxillectomies as the primary surgeon, which is cur-ently not the case. In fact, it is not even mentioned in theist of surgical minima to be undertaken during the residentraining period in otolaryngology.

onclusion

ubmaxillectomy is a surgical procedure with known risks.n our series, cases of marginal paresis were rare, with ourain complication being postoperative infections in cases

f chronic sialadenitis. Because it is a technique with clearndications that remain valid despite technological innova-ions, we believe that it should be included in the teachingrogram for resident otolaryngology physicians in a struc-ured manner.

onflict of Interests

he authors have no conflicts of interest to declare.

eferences

1. Yoel J. Atlas de cirugía de cabeza y cuello. Barcelona: Salvat;1991. p. 699---701.

2. Shah JP. Head and neck surgery. Barcelona: Mosby-Wolfe; 1996.p. 440---3.

3. Witt RL, Maygarden SJ. Benign tumors, cyst, and tumor-likecondition of the salivary glands. In: Witt RL, editor. Salivary

4

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

6

gland diseases. Surgical and medical management. New York:Thieme Medical Publishers; 2005. p. 114.

4. Upton DC, McNamar JP, Connor NP, Harari PM, Hartig GK.Parotidectomy: ten-year review of 237 cases at a single institu-tion. Otolaryngol Head Neck Surg. 2007;136:788---92.

5. Eggers G, Chilla R. Ultrasound guided lithotripsy of salivary cal-culi using an electromagnetic lithotriptor. Int J Oral MaxillofacSurg. 2005;34:890.

6. Marchal F. Sialendoscopy. In: Myers EN, Ferris RL, editors. Sali-vary gland disorders. Berlin: Springer; 2007. p. 127---49.

7. Baptista PM, Gimeno-Vilar C, Rey-Martínez JA, Casale-FalconeM. Sialoendoscopia: una nueva alternativa en el tratamiento dela patología salival. Nuestra experiencia. Acta OtorrinolaringolEsp. 2008;59:120---3.

8. Shekar K, Singh M, Godden D, Puxeddu R, Brennan PA. Recentadvances in the management of salivary gland disease. Br J OralMaxillofac Surg. 2009;47:594---7.

9. Preuss SF, Klussmann JP, Wittekindt C, Drebber U, Beutner D,Guntinas-Lichius O. Submandibular gland excision: 15 years ofexperience. Oral Maxillofac Surg. 2007;65:953---7.

0. Berini-Aytes L, Gay-Escoda C. Morbidity associated withremoval of the submandibular gland. J Craniomaxillofac Surg.1992;20:216---9.

1. Ellies M, Laskawi R, Arglebe C, Schott A. Surgical managementof nonneoplastic diseases of the submandibular gland. A follow-up study. Int J Oral Maxillofac Surg. 1996;25:285---9.

2. Gallo O, Berloco P, Bruschini L. Treatment for non-neoplasticdisease of the submandibular gland. In: McGurk M, Renehan AG,editors. Controversies in the management of salivary gland dis-ease. Oxford (UK): Oxford University Press; 2001. p. 297---310.

3. De M, Kumar Singh P, Johnson AP. Morbidity associated with sub-mandibular gland excision: a retrospective analysis. Internet JHead Neck Surg. 2007;1:1.

4. Ichimura K, Nibu K, Tanaka T. Nerve paralysis after surgery in thesubmandibular triangle: review of University of Tokyo hospital

experience. Head Neck. 1997;19:48---53.

5. Hald J, Andreassen UK. Submandibular gland excision: short-and long-term complications. ORL J Otorhinolaryngol RelatSpec. 1994;56:87---91.

2

M. Hernando et al.

6. Smith WP, Peters WJ, Markus AF. Submandibular gland surgery:an audit of clinical findings, pathology and postoperative mor-bidity. Ann R Coll Surg Eng. 1993;75:164---7.

7. Milton CM, Thomas BM, Bickerton RC. Morbidity studyof submandibular gland excision. Ann R Coll Surg Engl.1986;13:148---50.

8. Kennedy PJ, Poole AG. Excision of the submandibular gland:minimizing the risk of nerve damage. Aust N Z J Surg.1989;59:411---4.

9. Bates D, O’Brien CJ, Tikaram K, Painter DM. Parotid and sub-mandibular sialadenitis treated by salivary gland excision. AustN Z J Surg. 1998;68:120---4.

0. Goh YH, Sethi DS. Submandibular gland excision: a five-yearreview. J Laryngol Otol. 1998;112:269---73.

1. Leonardo BA, Cosme GE. Morbidity associated with theremoval of the submandibular gland. J Craniomaxillofac Surg.1992;20:216---9.

2. Woltmann M, Faveri R, Sgrott EA. Anatomosurgical study of themarginal mandibular branch of the facial nerve for submandibu-lar surgical approach. Braz Dent J. 2006;17:71---4.

3. Guerrissi JO, Taborda G. Endoscopic excision of the sub-mandibular gland by an intraoral approach. J Craniofac Surg.2001;12:299---303.

4. Ryan M, Kauffman MD, James L, Netterville MD, Brian B,Burkey MD. Transoral excision of the submandibular gland:techniques and results of nine cases. Laryngoscope. 2009;119:502---7.

5. Song CM, Jung YH, Sung MW, Kim KH. Endoscopic resection ofthe submandibular gland via a hairline incision: a new surgicalapproach. Laryngoscope. 2010;120:970---4.

6. Hong KH, Kim YK. Intraoral removal of the submandibulargland: a new surgical approach. Otolaryngol Head Neck Surg.2000;122:798---802.

7. Weber SM, Wax MK, Kim JH. Transoral excision ofthe submandibular gland. Otolaryngol-Head Neck Surg.

2007;197:343---5.

8. Capaccio P, Torretta S, Pignataro L. The role of adenectomyfor salivary gland obstructions in the era of sialendoscopy andlithotripsy. Otolaryngol Clin North Am. 2009;42:1161---71.