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Transoral Approach to Submandibular Gland Surgery Seen as Practical

From: ENT Today, April 2009

by Ed Susman

Removal of the submandibular gland using an oral pathway appears to be feasible and successful, doctors have reported.

The transoral excision of the submandibular gland avoids a neck incision and a subsequent neck scar, said Ryan Kauffman, MD, a resident in otolaryngology at Vanderbilt University in Nashville, presenting his findings at the 111th annual meeting of the Triological Society. In addition, the transoral route may decrease volume loss in Level 1B of the floor of the mouth due to limited tissue disturbance. There is also a decreased the probability of injury to the marginal mandibular branch of the facial nerve. There also is no need for a surgical drain postoperatively.

Description of the Technique

In performing the transoral surgery technique, Dr. Kauffman illustrated how the surgeon identifies key nerves and blood vessels, using blunt dissection of these structures to protect them from damage and to control bleeding. Of particular interest are the identification of the lingual nerve, the hypoglossal nerve, and Wharton's duct, as well as locating the branches of the facial artery and facial vein.

Mark Weissler, MDAlthough the technical exercise is certainly possible, the authors suffered three moderately severe complications, and one patient had to be converted to an open approach. The facial artery, in particular, represents a major branch from the external carotid system, and incomplete ligation or loss of control could prove catastrophic.
-Mark Weissler, MD

Dr. Kauffman described the procedure: After counseling, general anesthesia is induced, and the neck is prepped and marked in the standard fashion for transcervical submandibular gland excision. A Dingman mouth gag is placed in an inverted fashion into the oral cavity. An endoscope can be utilized to provide improved light and magnification to the surgical field.

The tongue is then retracted to the contralateral side of operation, and bimanual palpation of the floor of mouth identifies any Wharton's duct calculi, and also identifies the position and size of the gland. This maneuver also allows for delivery of the superior portion of the gland. After infiltration of lidocaine with epinephrine, the incision is created from the retromolar trigone to within 1 cm of the lingual surface of the alveolar ridge, at the caruncle of Wharton's duct.

Dissection along Wharton's duct from the caruncle of the duct to the gland identifies the lingual nerve, located on the superior-posterior-lateral surface of the gland, which is carefully dissected away. Also, its course inferior to the duct is traced lateral to medial. Wharton's duct is circumferentially dissected, from the caruncle to the gland, so that it may be elevated and excised en bloc with the gland.

The gland is then dissected off of the muscles of the tongue and floor of mouth. Posteriorly and laterally, dissection identifies the facial artery and vein branches involved in the gland, which are clipped and divided. After dissection of the anterior and lateral portions of the gland, the hypoglossal nerve should be identified inferior and lateral to the gland. The submandibular ganglion is identified and divided from the lingual nerve. The wound is then irrigated, inspected for hemostasis and intact neural and vascular structures, and closed with interrupted 4-0 chromic sutures, leaving a small opening posteriorly for blood efflux.

Five days of antibiotics to cover oral flora are given. The patient returns for postoperative evaluation in three weeks.

Ryan Kauffman, MDThe transoral excision of the submandibular gland avoids a neck incision and a subsequent neck scar. In addition, the transoral route may decrease volume loss in Level 1B of the floor of the mouth due to limited tissue disturbance.
-Ryan Kauffman, MD

Case Series Review

In his presentation, Dr. Kauffman reviewed a case series that involved nine patients who were managed by transoral surgery for treatment of recurrent sialidenitis/sialothiasis, benign cystic oral floor masses, or benign salivary gland masses.

The cases were attempted during the past 10 years, but most of them had been performed since February 2007. Eight operations were completely transoral, he said. The indications for surgery are the same whether the procedure is done in the traditional method or by the transoral approach.

The procedure is contraindicated in patients with suspected or proven malignant masses or an anatomic abnormality that could limit visibility within the oral cavity, he said.

We have found that transoral excision of the submandibular gland is a viable and safe approach, Dr. Kauffman said. The surgeries did not result in any permanent complications involving the facial, lingual or hypoglossal nerves, he said. He also noted that the patients did not experience any hemostatic complications.

Dr. Kauffman said that in the one procedure that could not be performed through the transoral route, surgeons were forced to convert to the open excision because of severe scarring and a 2.0 cm sialolith. Five of the nine patients were able to go home on the day of the surgery; two others went home after a 24-hour hospital stay.

Six of the patients were treated for chronic sialodenitis-and three of those patients had obstructing sialoliths, he said. The other patients had benign lesions: a ranula, and infected mucocele and a cystic teratoma. The patients ranged in age from 8 to 77 years; six were female.

Two of the eight patients who had completed transoral surgeries later experienced temporary changes in tongue sensation, which resolved within six weeks. None of them complained of a permanent change in sensation. Another patient experienced delayed healing in an area that had previous undergone radiation therapy for head and neck cancer treatment.

Ready for Prime Time?

Whether the procedure is ready for prime time, however, is not proven, said Mark Weissler, MD, the Joseph P. Riddle Distinguished Professor of Otolaryngology and Chief of the Division of Head and Neck Oncology at the University of North Carolina in Chapel Hill. Although the technical exercise is certainly possible, the authors suffered three moderately severe complications, and one patient had to be converted to an open approach. The facial artery, in particular, represents a major branch from the external carotid system, and incomplete ligation or loss of control could prove catastrophic, he said.

Dr. Weissler noted that in performing the submandibular gland resection, doctors will be involved with present or past inflammation and scarring. I am not convinced of the utility of this procedure, he said.

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©2009 The Triological Society

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