surgical results of the intraoral removal of the submandibular gland

7/23/2019 Surgical results of the intraoral removal of the submandibular gland

http://slidepdf.com/reader/full/surgical-results-of-the-intraoral-removal-of-the-submandibular-gland 1/5

ORIGINAL RESEARCH—GENERAL OTOLARYNGOLOGY

Surgical results of the intraoral

removal of the submandibular gland

Ki Hwan Hong, MD, and Yun Su Yang, MD, Chonju, Chonbuk, Korea

OBJECTIVES: Most patients with benign submandibular disor-

ders have been treated surgically without difficulty via the tran-

scervical 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 ap-

proach before proper expert, especially in the severe adhesion of

salivary gland to surrounding tissue.

© 2008 American Academy of Otolaryngology–Head and Neck

Surgery Foundation. All rights reserved.

Chronic inflammatory reaction of the submandibular

gland often results in irreversible histologic changes of

salivary tissue. These conditions may require removal of the

submandibular gland.1-3 The transcervical approach for

these disorders is generally accepted, but this approach has

several complications, such as a residual Wharton’s duct

inflammation, a residual cyst in the floor of the mouth, and

neurologic complications.4-6 Actually the Wharton’s duct

could be not totally removed via the transcervical approach.

The residual cyst after transcervical removal of the subman-dibular gland resulted from the genesis of mucocele due to

injury of the sublingual gland or a mucous retention cyst

due to the obliteration of the sublingual duct. The injury of

the marginal mandibular nerve is a most common compli-

cation in the transcervical approach. It consists of a tempo-

rary or permanent paralysis mainly due to compression

and/or stretching of the marginal mandibular nerve. The

temporary paralysis resolves spontaneously within a period

of 3 months. The hypoglossal nerve injury is rare in the

transcervical removal of the submandibular gland. When

the hypoglossal nerve is intact, the tongue movement should

be normal neurologically. However, some patients with the

transcervical approach temporarily showed a mild limited

movement of the tongue due to swelling of the floor of the

mouth and/or injury to the extrinsic tongue muscle. This

symptom completely resolved itself within the first week

after surgery.In the literature review, since Downton and Qvist7 first

reported an intraoral approach for chronic sialadenitis of the

submandibular gland in 1960, no further reports have been

found until the Hong and Kim8 report. Downton and Qvist7

made the incision on the lingual side of the necks of the

teeth when the molar teeth were present. In the edentulous

patients, a curved incision was made through the periosteum

along the alveolus from the retromolar pad to the canine

region. In their procedure, the mucoperiosteum was re-

flected medially, and the mylohyoid muscle was separated

from its attachment to the mandible. However, Hong and

Kim8 incised the mucosa on the floor of the mouth along the

Wharton’s duct when the molar teeth were present, and a

more lateral incision was made in the edentulous patients.

The periosteal incision and separation of the mylohyoid

muscle from the mandible are not necessary. Downton and

Qvist7 suggested that the surgery was more difficult when

the molar teeth were present, and it was sometimes neces-

sary to make a small cervical incision simultaneously. In the

Hong and Kim intraoral approach, an additional cervical

incision is not necessary when the molar teeth are present.

However, in the chronically inflamed disorders of the sub-

mandibular gland, the intraoral dissection of the gland ishardly performed due to the severe adhesion to the sur-

rounding tissue, and this may alter the approach to the

transcervical route.

In this study, we evaluated the surgical results associated

with the intraoral approach in a series of 77 operations for

chronic sialadenitis and benign mixed tumors in the sub-

mandibular gland.

Received May 11, 2007; revised January 7, 2008; accepted January 23,

2008.

Otolaryngology–Head and Neck Surgery (2008) 139, 530-534

0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.doi:10.1016/j.otohns.2008.01.008



SUBJECTS

The age, sex, postoperative complications and long-term

morbidity of 77 patients with benign submandibular disor-

ders were reviewed for the 10 years since 1997. The simple

intraoral stone removal was not included and bilateral pro-

cedures were not performed. An Institutional Review Board

is not available in our institution, but we obtained properconsent from the patients in keeping with the mandate of the

Declaration of Helsinki. The study’s aim, methods, and all

potential risks and benefits to each patient were explained as

part of the consent process. All subjects were informed of

their right to abstain from participation in the study. No

potential subjects were found to be legally incompetent.

SURGICAL TECHNIQUE

After transnasal intubation and proper oral preparation withhydrogen dioxide and saline irrigation, the incision should

be made through the mucosa of the lateral floor of the mouth

from the orifice of the Wharton’s duct to the lingual side of

the retromolar region (Fig 1). The sublingual gland is then

dissected and totally removed with the isolation of the

Wharton’s duct and preservation of the lingual nerve (Figs

2 and 3). The duct should be cut and ligated at the orifice of

Wharton’s duct. The duct is isolated along the lingual nerve

to the hilum of the submandibular gland. The submandibu-

lar ganglion, lying immediately inferior to the lingual nerve,

can be noted by blunt dissection of the gland capsule from

the surrounding tissue. With medial retraction of the tongueand floor of the mouth including the lingual nerve and

lateral retraction of the mylohyoid muscle, the submandib-

ular gland should be visible. The gland is exposed more

prominently by digital pressure applied beneath the lower

border of the mandible (Fig 4). For good exposure and

lighting of the surgical field, the fiberoptic retractor should

be used. The gland should be gripped with long tissue

forceps or tonsil hemostatic forceps, dissected with the

tonsil dissector or dissecting scissors, and pulled up through

the incision. The loop of the facial artery and arterial

branches to the gland are noted by blunt dissection and can

frequently be freed completely from the gland. The artery to

the submandibular gland should always be ligated or

clipped with a hemoclip to prevent severe bleeding during

dissection and postoperative hematoma. After removal of

the submandibular gland, the hypoglossal nerve should be

identified in the bed of the surgical field, and bimanualpalpation should be applied to detect residual gland in the

submandibular space. The incised mucosa is then sutured

back loosely with silk sutures. A suction drain is inserted

through the intraoral incision site and removed the first or

second postoperative day according to the drain output.

Figure 1 Mucosal incision on the floor of mouth.

Figure 2 Lingual nerve and Wharton’s duct after total removal

of the sublingual gland.

Figure 3 Uncrossing the Wharton’s duct from lingual nervesubmandibular gland.

531Hong and Yang Surgical results of the intraoral . . .



RESULTS

Thirty-four (44%) patients were male and 43 (56%) were

female; the male to female ratio was 1: 1.2 (Table 1). The

age of the patients ranged between 13 and 67 years, with a

mean age of 36.4 years. The final diagnosis of sialolithiasis,

based on the observation of sialoliths by the surgeon and/or

the pathologist, was established in 47 (61.0%) cases. A

previous intraoral stone removal had been performed in 9

(19%) cases among the patients with a stone. A total of 20

(25.9%) cases of sialadenitis without a stone were classifiedas chronic sialoadenitis. Nine (11.7%) cases of benign ple-

omorphic adenomas were also treated via the intraoral ap-

proach.

As shown in Table 2, early postoperative complications

were observed in most of the patients. A temporary lingual

nerve injury (such as paresthesia of the tongue) in 57

(74.01%) cases resolved within 3 to 4 weeks in all cases; a

mild limited movement of the tongue in 54 (70.1%) cases

resolved within 4-6 weeks except for 2 cases. 2 cases of

wound bleeding, and 2 cases of abscess formation. Late

postoperative complications after 3 months appeared as

follows: 4 cases of lingual paresthesia that were tolerable in

all patients and resolved later, 2 cases of asymmetry of the

tongue movement that were not symptomatic and only

physically noted, and 4 cases of the residual salivary tissue

palpated on the neck. Gustatory sweating symptom (Frey’s

syndrome) was observed in 1 case. No residual inflamma-

tion in the Wharton’s duct and no external scar were noted.

No injuries of the hypoglossal or marginal mandibular

nerves were noted.

DISCUSSION

On the surgical approach for the benign submandibular

disorders, the transcervical approach is widely accepted and

relatively simple, and the salivary gland tissue could beremoved without difficulty and without alteration of the

salivary system. However, the transcervical procedure has

frequently been associated with neurologic complications

after surgery, including the marginal mandibular nerve and

lingual and hypoglossal nerves. Alternative surgical ap-

proaches have been developed to avoid neurologic risks and

visible scarring in the upper neck. Hong and Kim8 reported

a new surgical approach for intraoral removal of benign

submandibular disorders and suggested that the intraoral

approach could be extended as an alternative to the trans-

cervical approach. However, this approach has also a few

problems, such as temporal sensory paresis and limitedmovement of tongue, but resolved spontaneously, and in the

Figure 4 Dissection of submandibular gland with digital pres-

sure and identification of facial artery or its branch to the subman-

dibular gland.

Table 1

Distributions of submandibular disorder

Diagnosis Number (%)

Chronic sialoadenitis with stone 47 (61.0)Chronic sialoadenitis 20 (25.9)Pleomorphic adenoma 9 (11.7)Chronic sialoadenitis with ranula 1 (1.3)Total 77 (100)

Age ranged from 13 to 67 years.

Sex distributions: male 34, female 43.

Table 2

Complications after submandibular gland excision

Complications Transcervical*

Intraoral

(%)†

Early complications

Infection (abscess) 7.3 2 (2.6)Bleeding 3.8 2 (2.6)Limited tongue motion ? 54 (70.1)

Late complicationResidual duct

inflammation 7.3 0Residual salivary tissue ? 4 (5.2)Unaesthetic scar 4.8 0Gustatory sweating 0.5 1 (1.3)Neurologic

complicationsMandibular nerve,

temporal 11.6 0permanent 7.7 0

Lingual nerve, temporal 4.4 57 (74.0)permanent 1.4 0

Hypoglossal nerve,

temporal 3.4 0permanent 2.9 0

*Berini-Aytes and Gay-Escoda cases, 251 patients involved.

†Hong and Kim cases, 77 patients involved.

532 Otolaryngology–Head and Neck Surgery, Vol 139, No 4, October 2008



severe adhesion to surrounding tissue the intraoral dissec-

tion of gland is not easily dissected. Recently, to improve

cosmetic results, minimally invasive endoscopic and endo-

robotic methods of submandibular gland resection through

various routes have been assessed in experimental9-11 and

clinical studies.12,13 The operation time of endoscopic sur-

gery, however, is significantly longer than that of other

procedures.

On retrospective review of the surgical data during our

study period, only 11 patients were treated via the transcer-

vical approach for the benign disorders of submandibular

gland. Except for an external scar, they did not show any

definite sequelae, including neurologic defects of lingual

and hypoglossal nerves. Some patients showed a little

asymmetry of the lower lip due to cutting of the plastysma

muscle of the submandibular area; they recovered normally

and were not symptomatic at all. In our study, the intraoral

procedure for submandibular excision has also minor com-

plications after surgery. Two cases of bleeding and 3 cases

of infected abscess were noted. During dissection of the

submandibular gland via the transcervical route, the loop of

the facial artery or arterial branches to the gland should be

easily noted and could frequently be freed completely from

the gland. However, to demonstrate and ligate the artery to

the submandibular gland in the intraoral approach may not

be easy without sufficient experience.8 Experience and a

detailed knowledge of the anatomy for proper dissection

could reduce bleeding. In our 2 cases of postoperative

bleeding, the submandibular area and floor of the mouth

swelled up immediately after surgery. Bleeding was con-

trolled during an urgent procedure in the operating room

under general anesthesia. The bleeding points were

branches of the facial artery and were controlled via the

transcervical route in 1 patient and the intraoral route in the

other patient.

The intraoral approach may offer more chances for con-

tamination from the oral cavity to the submandibular space.

However, with proper preoperative preparation and contin-

uous suction drainage with the hemovac through the oral

cavity after dissection, an infection is preventable. In this

intraoral approach the hypoglossal nerve should be identi-

fied at all times and never injured, but mild limitation of

tongue movement was noted also with 70 percent of thepatients. The swelling of the lateral tongue and floor of the

mouth was observed on physical examination and resulted

in temporary limited tongue movement and articulation dif-

ficulty during speech. This resolved itself within 2 weeks.

However, in 2 cases, a slight limitation of tongue movement

was noted physically, but not symptomatically, due to scar

contracture on the floor of the mouth.

The residual duct inflammation could be noted in 3

percent to 12 percent of the patients as late complications of

the transcervical approach.4,14,17 The Wharton’s duct could

not be removed completely in the transcervical approach,

but with the intraoral approach the duct can be completelyremoved because the duct is cut and ligated at the orifice.

Therefore, the residual duct inflammation was not observed

in this intraoral approach. The cause of a residual cyst in the

mouth floor after the transcervical removal of the subman-

dibular gland can be explained by the genesis of mucoceles

due to injury of the sublingual gland or mucous retention

cysts due to obliteration of the ducts of Rivinus. An inci-

dence of a residual cyst can be up to 6 percent.14 This cyst

can be observed mainly in the anterior floor of mouth, but

sometimes in the posterior floor of mouth. In the intraoral

approach, the sublingual gland should be removed totally

for a proper surgical field; dissection of the submandibular

gland and the residual cyst does not occur in this approach.

During the transcervical dissection of the submandibular

gland, the salivary tissue may be removed completely, but a

small amount of salivary tissue could be left. A small

amount of salivary tissue may not induce the clinical prob-

lems because of atrophy of salivary tissue.15 However, in

this study, 3 patients showed a small palpable mass on the

submandibular area 6 months after surgery. One patient’s

mass decreased and clinically caused no problems, but 2

patients showed a protruded and reddish mass on the skin.

The masses were removed via a small incision on the neck

skin and showed up as salivary tissue pathologically. On

retrospective review, these 3 patients underwent surgery in

the beginning of our intraoral experience; at that time we

were inexperienced. However, with experience, we im-

proved our surgical technique to remove all submandibular

tissue, and no further residual salivary tissue was noted.

As to the aesthetic problem, the transcervical incision

may induce a scar problem, especially in young women or

keloid characters. However, a major advantage of this ap-

proach is the avoidance of external scarring, especially in

young patients or keloid characters. The submandibular area

involved appears as a little dimpling, but not distinct exter-

nally in most patients.

As to neurologic complications, an injury of the mandib-

ular branch of the facial nerve is the most common com-

plication in the transcervical approach. Milton et al16 re-

ported an 18 percent incidence of damage to the marginal

mandibular nerve; 7 percent were permanent. It usually

consists of a temporary paralysis due to a compression

and/or stretching injury, which can resolve spontaneously

within a period of 3 months.

17

However, in the intraoralapproach, the marginal mandibular nerve is not exposed

during dissection, and there is no possibility of the facial

nerve injury. This is also a major distinct advantage of the

intraoral approach. In the transcervical approach, the lingual

nerve should always be identified. Lesions associated with

this nerve are not common, and if they do occur, they are

temporary. A 3 percent incidence of permanent neurologic

deficit was described by Milton et al,16 while Turco et al18

reported alterations of lingual sensitivity in 6 percent of

cases. Goudal and Bertrand14 reported that 12 percent of the

patients in their study presented neurologic sequelae, but

only 4.8 percent of these were permanent. This incidencewould have been higher if systematic examination had been

533Hong and Yang Surgical results of the intraoral . . .



carried out. However, in the intraoral approach, the lingual

nerve is always compressed and/or stretched during traction

of the floor of mouth, and the neurologic problem of lingual

nerve injury was observed in most patients temporarily.

Most patients showed temporary injury that lasted 2 to 3

weeks along the side of the tongue. Four patients com-

plained of a mild reduced sense of the tongue that lasted 3months after surgery, but resolved by long-term follow-up.

The hypoglossal nerve is a critical structure that should be

identified at all times3,5 in the transcervical approach and in

the intraoral approach.8 The incidence of this nerve injury is

rare, about 1 percent, in the transcervical approach,13 but

not observed at all in the intraoral approach. Berini-Aytes

and Gay-Escoda4 reported 1 case of the gustatory sweating

syndrome, which resolved spontaneously. In other series,

this syndrome also occurred exceptionally.16,19 In this in-

traoral approach, 1 case of the gustatory sweating syndrome

occurred. The avoidance of this syndrome has been one of

the motives cited in support of the preservation of thesubmandibular ganglion of the lingual nerve.15,20

CONCLUSION

This intraoral approach could be extended as an alternative

to the transcervical approach. The major advantages of this

approach are the avoidance of an external scar and of injury

to the mandibular branch of the facial nerve or the hypo-

glossal nerve. However, most patients temporarily com-

plained of neurologic problems of the lingual nerve, butthese were completely resolved within at least 2 months

after surgery. In the severely adhered salivary gland, the

intraoral dissection may not be possible, in which case, the

surgical method should be altered to the complementary

transcervical excision. The arterial branches to the subman-

dibular gland should always be ligated for prevention of

bleeding.

AUTHOR INFORMATION

From the Department of Otolaryngology–Head and Neck Surgery, Chon-buk National University, Medical School, Chonju, Chonbuk, 561-712,

Korea.

Corresponding author: Ki Hwan Hong, MD, Department of Otolaryngology–

Head and Neck Surgery, Chonbuk National University, Medical School

Chonju, Chonbuk, 560-182, Republic of Korea.

E-mail address: [email protected].

AUTHOR CONTRIBUTION

Ki Hwan Hong, study design and writer; Yun Su Yang, data collection.

FINANCIAL DISCLOSURE

None.

REFERENCES

1. van den Akker HP, Besemann-Sokole E. Submandibular gland func-

tion following transoral sialolithectomy. Oral Surg 1983;56:351–6.

2. Isacsson G, Isberg A, Haverling M, et al. Salivary calculi and chronic

sialoadenitis of the submandibular gland: a radiographic and histologic

study. Oral Surg 1984;58:622–7.

3. Beahrs OH, Woolner LB. Surgical treatment of diseases of salivary

gland. Oral Surg 1969;27:119–28.

4. Berini-Aytes L, Gay-Escoda C. Morbidity associated with removal of

the submandibular gland. J Craniomaxillofac Surg 1992;20:216–9.

5. Eichel BS, Bray DA, Kaplan HJ, et al. The overall management of salivary gland disorders. Laryngoscope 1981;91:504–11.

6. Blatt I. Inflammation of the salivary glands. Laryngoscope 1966;76:

917–33.

7. Downton D, Qvist G. Intraoral excision of the submandibular gland.

Proceedings of the Royal Society of Medicine 1960;53:543–4.

8. Hong KH, Kim YK. Intraoral removal of the submandibular gland: a new

surgical approach. Otolaryngol Head Neck Surg 2000;122:798–802.

9. Monfared Y, Saenz Y, Terris DJ. Endoscopic resection of the

submandibular gland in a porcine model. Laryngoscope 2002;112:

1089–93.

10. Guyot L, Duroure F, Richard O, et al. Submandibular gland endo-

scopic resection: a cadaveric study. Int J Oral Maxillofac Surg 2005;

34:407–10.

11. Terris DJ, Haus BM, Gourin CG, et al. Endo-robotic resection of the

submandibular gland in a cadaver model. Head Neck 2005;27:946–51.

12. Chen MK, Su CC, Tsai YL, et al. Minimally invasive endoscopic

resection of the submandibular gland: a new approach. Head Neck

2006;28:1014–7.

13. Roh JL. Removal of the submandibular gland by a retroauricular

approach. Arch Otolaryngol Head Neck Surg 2006;132:783–7.

14. Goudal JY, Bertrand JC. [Complications of surgical treatment for

submandibular calculi]. Rev Stomatol Chir Maxillofac 1979;80:

349–50.

15. Yoel J. Pathology and surgery of the salivary glands, 3rd ed. Spring-

field, IL: Charles C Thomas Publisher; 1975. pp. 820–1136.

16. Milton CM, Thomas BM, Bikerton RC. Morbidity study of subman-

dibular gland excision. Ann R Coll Surg Engl 1986;68:148–50.

17. Marynard J. Contemporary surgery: submandibular and parotid resec-

tion. Br J Hosp Med 1978;20:70.18. Turco C, Nision A, Brunetti F. [Submandibular sialoadenectomy and

long-term results]. Minerva Stomatol 1988;37:329–33.

19. Bailey BM, Pearce DE. Gustatory sweating following submandibular

salivary gland removal. Br Dent J 1985;158:17–8.

20. Rankow RM, Polayes IM. Inflammatory disorders. Surgical manage-

ment. In: Rankow and Polayes: Diseases of the salivary glands. Phil-

adelphia: WB Saunders; 1976. pp. 229-38.

534 Otolaryngology–Head and Neck Surgery, Vol 139, No 4, October 2008

mailto:[email protected]



surgical results of the intraoral removal of the submandibular gland

Documents