submandibular gland excision

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Excision of Submandibular Gland Dr. Maamon Ameen

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Page 1: Submandibular gland excision

Excision of Submandibular Gland

Dr.Maamon Ameen

Page 2: Submandibular gland excision

ANATOMY

• Submandibular gland is one of the three paired salivary glands. • Size of a walnut• Mixed gland with predominantly serous in

type • Responsible for about 70% of salivary

secretion.

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ANATOMY• Situation: Digastric triangle and lodges partly

in the submandibular fossa of the mandible• Part of gland : Large superficial part Small

deep part continous with each other around the post. Border of mylohyoid

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ANATOMY

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ANATOMYWhartons duct• 5 cm long• Emerges at the anterior end of

deep part of the gland• Runs forwards on hyoglossus b/w

lingual and hypoglossal N• At the ant. Border of hyoglossus it

is crossed by lingual nerve• Opens in the floor of mouth at the

side of frenulum of tongue

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SURGICAL ANATOMY

The digastric muscle • forms the anteroinferior and

posteroinferior boundaries of the submandibular triangle.

• It is an important surgical landmark as there are no important structures lateral to the muscle.

• The facial artery emerges from immediately medial to the posterior belly, and the XIIn runs immediately deep to the digastric tendon.

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SURGICAL ANATOMY

Mylohyoid muscle • key structure when excising the

SMG, as it forms the floor of the mouth, and separates the cervical from the oral part of the SMG.• The lingual and XIIn are both

deep to the muscle.

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SURGICAL ANATOMY

Marginal mandibular nerve • Is at risk of injury.• It runs within the investing layers of deep

cervical fascia overlying the gland.• May loop up to 3cms below the ramus of

the mandible. • It crosses over the facial artery and vein

before ascending to innervate the depressor anguli oris muscle of the lower lip.

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SURGICAL ANATOMY 3 methods of preserving

1. Approaching the gland at the level of hyoid bone, and keeping the dissection deep to the glands facial covering.

2. Dividing the facial vessels well below the mandible and on lifting up the upper ligated stumps.

3. Identify tail of parotid where it lies anterior to retromandibular vein and to trace it forward

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SURGICAL ANATOMY

lingual nerve • comes into view during SMG excision

when the SMG is retracted inferiorly, and the mylohyoid is retracted anteriorly.

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SURGICAL ANATOMY Hypoglossal nerve (XIIn) • Enters the submandibular triangle

posteroinferiorly and medial to the hyoid bone.

• The XIIn is covered by a thin layer of fascia, distinct from the SMG capsule.• Accompanied by thin walled ranine veins that

are easily torn at surgery.

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SURGICAL ANATOMY Facial artery • Enters the submandibular triangle

Posteroinferiorly from behind the posterior belly of digastric and stylohyoid.• Courses across the posteromedial

surface of the SMG.• Reappears at the superior aspect of the

SMG where it joins the facial vein to cross the mandible.

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Excision of Submandibular Gland

Indications • Repeated enlargement of the gland. • Salivary gland calculi• Chronic salivary gland infection.• Duct stenosis • Suspected submandibular neoplasm

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PREOPERATIVE EVALUATION History• History of swellings (onset ,duration, recurrence )• Pain• Variation with meals• Bilateral• Dry mouth• Radiation history• Recent operative history

Excision of Submandibular Gland

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Examination : Inspection• Asymmetry (glands, face, neck)• Diffuse or focal enlargement• Erythema • Trismus• Medial displacement of structures intraorally• Cranial nerve examination

Excision of Submandibular Gland

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Examination : Palpation• Bimanual palpation of floor of mouth in

a posterior to anterior direction.• Palpation of duct papilla.• Bimanual palpation of the gland (firm

or spongy)• Palpate for cervical lymhadenopathy

Excision of Submandibular Gland

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INVESTIGTIONS • Plain X-ray• Ultrasound• Sialography • CT and MRI scanning• Fine-Needle Aspiration Biopsy

Excision of Submandibular Gland

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LATERAL MANDIBULAR VIEW TRANSORAL OCCLUSAL VIEW

Excision of Submandibular Gland

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Advantagedetects

radiolucent stones

Disadvantage

• invasive• bleeding &

perforations

contraindicated• acute infections• allergic to

contrast

Sialography

Excision of Submandibular Gland

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Ultrasound: differntiate between • solid versus cystic lesion • Intrinsic from extrinsic

Excision of Submandibular Gland

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CT scaninvolvement of the mandible, the presence or absence of pathologic lymphadenopathy local extent of the tumor.

Excision of Submandibular Gland

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Fine-Needle Aspiration Biopsy • Useful tool for differentiating chronic inflammatory disease

from neoplasia.

Excision of Submandibular Gland

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Surgical approaches

• Transcervical approach• Transoral approach

Excision of Submandibular Gland

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Trans-cervical approach

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TRANS-CERVICAL APPROACH

Informed ConsentMarginal mandibular nerve>possibility of weakness of

the lower lip. Lingual > numbness of the tongue Hypoglossal nerves > paralysis of the tongue on the

operated side

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OPERATION STEPSAnesthesia • General anesthesia • Avoid muscle relaxant to monitor lower lip movement

TRANS-CERVICAL APPROACH

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OPERATION STEPS

• Positioning and draping

• Incision 3-4 cm below the mandible or at the level of hyoid bone

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• The incision is carried through skin,

subcutaneous tissue and platysma to expose the capsule of the SMG, the facial vein and posteriorly, the external jugular vein

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• The facial vein is ligated and divided where it crosses the SMG

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• The fascial capsule of the SMG is incised• subcapsular dissection

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• Dissect bluntly with a hemostat in the fatty tissue above the gland to identify the facial artery and vein • Divide and ligate facial artery

and vein as close as possible to SMG.

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• Front-to-back mobilisation of SMG off mylohyoid muscle, and division of mylohyoid nerve and vessels to gain access to the posterior border of mylohyoid muscle

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• Exposing posterior part of mylohyoid

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• Retracting mylohyoid brings lingual nerve, XIIn and submandibular duct into view

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• Finger dissection in plane between SMG and fascia covering XIIn and ranine veins

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• Division and ligation of submandibular duct and submandibular ganglion• follow and divide the duct more

anteriorly if surgery for sialolithiasis so as not to leave behind a calculus

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• The SMG can then be reflected inferiorly, and the facial artery is identified, ligated and divided where if exits from behind the posterior belly of digastric

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• The SMG is then finally freed from the tendon and posterior belly of the digastric and removed

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• Wound irrigation• Placement of suction drain• Wound is closed in layers

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Post-operative management• Head end elevation• NPO for 4-6hours• Patient observed for airway compromise• Monitoring of vital signs• I/V antibiotics• Analgesics• Removal of drain after 24-48hrs

Excision of Submandibular Gland

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Complications• General• Hematoma • Infection

• Specific• Marginal mandibular nerve injury• Lingual nerve injury• Hypoglossal nerve injury• Retained calculi in duct

Excision of Submandibular Gland

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Trans-oral approach

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• The submandibular gland can be safely and successfully removed through an intraoral approach in a select population of patients with benign pathology

TRANS-ORAL APPROACH

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Advantages of the transoral approach• less risk of injury to the marginal mandibular nerve • Avoidance of an external scar • Minimal risk of postoperative mucocele formation, or

inflammation of Wharton’s duct

TRANS-ORAL APPROACH

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Disadvantages • Narrow surgical field • Scar contracture in the floor of mouth • Temporary or permanent restriction of tongue movement, • Abnormal tongue sensation

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Contraindication • Suspected or proven malignancy, • Extensive scarring from prior abscessed gland • Surgeon lack of familiarity with the procedure

TRANS-ORAL APPROACH

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• Nasotracheal intubation• Injection of lidocaine with

epinephrine• Insertion of a probe into the orifice

of Wharton's duct

TRANS-ORAL APPROACH

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• An incision is made in the floor of mouth from the submandibular papilla to the retromolar trigone.• A cuff of mucosa on the gingival side

is preserved to allow for tension free closure and to prevent limitation of tongue mobility due to scar contracture

TRANS-ORAL APPROACH

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• The lingual nerve is identified and dissected free of its attachments to the submandibular duct and gland

TRANS-ORAL APPROACH

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• The submandibular gland is bluntly dissected and delivered into the surgical wound by applying external pressure on the neck• Branches of the facial artery and

vein are ligated with care not to disrupt the marginal mandibular branch of the facial nerve.

TRANS-ORAL APPROACH

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• The hypoglossal nerve is identified and preserved.

TRANS-ORAL APPROACH

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• The gland is removed• Wound bed irrigated and closed in a tension free manor

TRANS-ORAL APPROACH

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THANK YOU