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Submandibular Gland Excision

return to: Salivary Gland Surgery Protocols

see: Case example Submandibular Gland Resection

see: Case Example of Submandibular Gland Resection with Sialendoscopy to Avoid Retained Stone in Duct Remnant

see:Case Example 2 Retrograde Sialendoscopy to Prevent Retained Ductal Stone with Submandibular Gland Resection

see:Marginal Mandibular Nerve Weakness (Ramus Mandibularis) Level I Neck Dissection (extended) recurrent pleomorphic adenoma

see: Case Example Retained Submandibular Stone After Submandibular Gland Resection with neck fistula

GENERAL CONSIDERATIONS

    1. Indications
      1. Recurrent sialadenitis (infection) or obstructive sialodocholithiasis (salivary stones)
      2. Sialorrhea (drooling)
    2. Contraindication
      1. Suspicion of tumor: Removal of the gland should not be done as a "biopsy" to rule out tumor, whether benign or malignant. A formal "Level I neck dissection" rather than a "shell out" of the gland should be done unless the evaluation clearly points to a non-neoplastic indication for gland removal (see Selective Neck Dissection protocol).
      2. Poor medical condition: For those few patients who are unable to tolerate general anesthesia, the gland can be removed under local anesthesia if indicated.
  1. PREOPERATIVE PREPARATION
    1. Evaluation
      1. Consider CT (without contrast if looking for stones)
      2. Submental occlusal views may help to evaluate for those stones in Wharton's duct that are radio-opaque.
      3. Ultrasound with or without FNA
      4. Consider sialography.(see: Sialograms and Sialography)
      5. Unless clinical findings clearly indicate non-neoplastic process:
        1. Perform fine needle aspirate (FNA) biopsy
        2. CT or MRI
    2. Consent
      1. Describe procedure and incision.
      2. Describe location of relationship of gland to marginal mandibular nerve, lingual nerve, and hypoglossal nerve.
      3. Describe Wharton's duct and its relationship to the floor of mouth, sublingual glands, lingual and hypoglossal nerves.
      4. Describe expected sequelae:
        1. Numbness about incision
        2. Potential for altered lower lip contour from transection of platysma muscle and cervical branch of facial nerve
      5. Describe complications:
        1. Bleeding, infection, reaction to anesthetic agents
        2. Damage to adjacent structures: marginal mandibular nerve, lingual nerve, hypoglossal nerve
        3. Retained stone in distal stump of Wharton's duct
  2. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
    2. Instrumentation and Equipment
      1. Standard
        1. Major Instrument Tray 1, Otolaryngology
        2. Major Instrument Tray 2, Otolaryngology
        3. Bipolar Forceps Trays
      2. Special
        1. Varidyne vacuum suction controller
        2. Nerve stimulator control unit and instrument
        3. Consider use of sialendoscopes (sialendoscopy protocol) in a retrograde fashion to evaluate distal Wharton's duct for retained stone (selected cases)
    3. Medications (specific to nursing)
      1. Antibiotic ointment
      2. 1% lidocaine with 1:100,000 epinephrine
    4. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
        1. Head drape
        2. Square off incision site with towels to expose neck and lower face including lips
        3. Apply incise drape (clear) and/or 1010 drape to isolate contaminated oral cavity from the surgical field
        4. Split sheet
    5. Drains and Dressings
      1. Varidyne vacuum suction drain (7 mm or 10 mm) or Penrose drain
      2. Antibiotic ointment to suture line
  3. ANESTHETIC CONSIDERATIONS
    1. Preoperative Systemic Medications
      1. Antibiotics as soon as IV started (see Antibiotic protocol)
      2. Ensure patient is not paralyzed (to permit use of a facial nerve stimulator)
    2. Position
      1. Oral endotracheal intubation with tube secured to contralateral corner of mouth
      2. Table turned just past 90° to permit surgeons to be located on either side of the head
      3. Head of bed elevated to diminish bleeding
  4. OPERATIVE PROCEDURE
    1. Incision and Flap Elevation
      1. Along the relaxed skin tension lines, a horizontal incision is made at least 2 fingerbreadths below the mandible to ensure the marginal mandibular nerve is not damaged.
      2. The incision extends from the anterior border of the sternocleidomastoid (SCM) muscle to the midportion of the ipsilateral anterior belly of digastric muscle (close to the midline of the neck).
      3. The platysma is identified and incised to expose the anterior border of the SCM with care to avoid injury to the great auricular nerve.
      4. The posterior inferior aspect of the submandibular gland is identified immediately anterior to the sternocleidomastoid muscle where it overlays the posterior belly of the digastric muscle.
      5. A primary goal of flap elevation is to expose the submandibular gland without damaging the marginal mandibular nerve.
    2. Marginal Mandibular Nerve Preservation
      1. The marginal mandibular nerve may be preserved without identifying it by:
        1. Elevation of the fascia of the submandibular gland from an inferior to superior direction that carried the marginal mandibular nerve superiorly away from the gland.
        2. Elevation of the posterior facial vein will draw the marginal mandibular nerve superiorly away from the gland.
      2. The marginal mandibular nerve may be identified, dissected, and elevated separately superiorly above the mandible.
        1. This maneuver is necessary for a comprehensive Level I dissection to permit full removal of the contents of Level I including the prevascular and postvascular nodes around the facial artery as it courses over the mandible.
        2. Use of the nerve stimulator (Parson's McCabe) facilitates identification of the marginal mandibular nerve through stimulation or contraction of the depressors to the ipsilateral lower lip.
        3. Direct identification of the marginal mandibular nerve without the nerve stimulator may be effected by knowledge of its relationship to adjacent landmarks:
          1. The nerve overlies the posterior facial vein.
          2. The nerve underlies the platysma and overlies the submandibular gland.
          3. The cervical nerve branches to platysma are continuous with the marginal mandibular nerve and can be dissected proximally to encounter the nerve.
    3. Gland Removal
      1. Following flap elevation, the gland is exposed and retracted inferiorly, employing an Allis clamp or Babcock for traction.
      2. The digastric muscle is identified along its course including the common tendon and the anterior belly.
      3. The anterior aspect of the gland is mobilized posteriorly to expose the mylohyoid muscle.
      4. An Army-Navy retractor is placed under the posterior border of the mylohyoid muscle to retract anterosuperior to expose the lingual nerve.
      5. Bipolar cautery, medium-sized hemoclips, or suture ligature is placed to the submandibular ganglion permitting separation of the gland from the lingual nerve.
      6. The duct of the gland is traced anteriorly and transected after placement of a hemoclip as distal as possible. Retention of a segment of Wharton's duct may predispose to infection resulting from retained stone or debris in the duct.  With this in mind, performance of retrograde sialoendoscopy is recommended.
      7. The gland is dissected posteriorly to encounter the branch from the facial artery perfusing the gland.
        1. The facial artery may be left intact with suture ligature of the branch to the gland permitting removal of the gland from the wound.
        2. Alternatively, the facial artery may be suture ligated below the gland (after passing under the digastric muscle) and above the gland (before passing over the mandible).
      8. The hypoglossal nerve is not routinely displayed.
    4. Completion of Procedure
      1. Frozen section analysis is used to rule out the presence of tumor and will permit a more comprehensive Level I dissection if an unexpected benign or malignant tumor is identified.
      2. The wound is irrigated with saline and closed in layers over a drain.
        1. 3-0 or 4-0 vicryl or chromic subcutaneous
        2. 5-0 nylon to skin of the neck
      3. Drains
        1. Penrose drain may be placed, a light wrap around pressure dressing is applied (burn netting).
        2. A closed suction #7 or #10 flat, Jackson-Pratt fully perforated drain may alternatively be placed with no dressing other than antibiotic ointment is applied. 
        3. Choice of drains based on findings at surgery: if infection present, use passive (penrose drain); if no infection and no communication intra-orally, use closed suction drain.
  5. POSTOPERATIVE CARE
    1. Suction Drain Management
      1. The suction drain is left in for 36 hours minimum (longer depending on output).
      2. General rule: Remove drain only after three consecutive 8-hour shifts demonstrate a 24 hours cumulative output less than 30 cc.
      3. The drain may be managed in an outpatient setting.
    2. Antibiotics (see Antibiotic protocol)
    3. Suture removal on postoperative day 6.
  6. CPT CODING
    1. 42440, Excision of submandibular (submaxillary) gland
    2. 38700, Suprahyoid lymphadenectomy (see Neck Dissection protocols)
  7. SUGGESTING READING
    1. Hoffman H, Funk G, Endres G. Evaluation and surgical treatment of tumors of the salivary glands. In: Themley SE, Ponje WR, Botskis JG, Lindberg RD, eds. Comprehensive Management of Head and Neck Tumors. 2nd ed. Philadelphia, Pa: WB Saunders, 1999.

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