Gland Preservation Research Articles

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature.

Introduction For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation ( p = 0.047) . Conclusion Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

Anatomical localization of normal parathyroid glands before thyroidectomy through ultrasonography reduces postoperative hypoparathyroidism

Postoperative hypoparathyroidism due to dysfunction of the parathyroid gland is the most common complication after thyroidectomy. Our objective was to introduce the method of anatomical localization of normal parathyroid glands before thyroidectomy through ultrasonography and to evaluate its efficiency. The study group included 52 patients subjected to anatomical localization of the parathyroid gland prethyroidectomy through ultrasonography. The control group included 52 sex- and age-matched patients without parathyroid gland localization. The proportion of parathyroid glands preserved in situ and postoperative hypoparathyroidism rates in the 2 groups were compared. The rates of normal parathyroid glands identified according to ultrasonography for left superior, left inferior, right superior, and right inferior glands were 78.8%, 90.4%, 57.7%, and 82.7%, respectively. The rate of parathyroid gland excised inadvertently was significantly decreased (P = .038) in the study group as compared with the control group. The rates of parathyroid gland preservation in situ were significantly improved in the left superior (P = .001), left inferior (P = .002), and right inferior glands (P = .005). Furthermore, the incidence of transient hypoparathyroidism decreased significantly (P = .028). Our study indicated that normal parathyroid glands were identified by ultrasonography, and the anatomical localization improved the rate of parathyroid gland preservation in situ and decreased the incidence of transient hypoparathyroidism.

Application of Carbon Nanoparticles in Endoscopic Thyroidectomy via Bilateral Areola Approach: Total Thyroidectomy Plus Central Lymph Node Dissection.

Background: The aim of this report was dual: (a) to describe the step-by-step standardized intraoperative percutaneous injection of carbon nanoparticles (CNPs) procedure for CNP-stained central compartment lymph nodes (CLNs) and passive display of parathyroid gland by CNP-stained thyroid in endoscopic thyroidectomy via bilateral areola approach (ETBAA) and (b) evaluation and outcomes of percutaneous injection of CNPs in total thyroidectomy plus CLN dissection through ETBAA. Materials and Methods: Video describes the technique of intraoperative percutaneous injection of CNPs for central compartment LNs identification, dissection, and parathyroid glands preservation in ETBAA for papillary thyroid cancer. Results: Supplementary video shows that after intrathyroid injection of CNPs, black carbon can be seen rapidly along the lymphatic vessels to the surrounding LNs. Parathyroid gland can be passive display when the thyroid is black and the parathyroid gland is normal in color. Intraoperative neuromonitoring (Medtronic® NIM-Response 3.0) was applied to identify recurrent laryngeal nerve and external branch of superior laryngeal nerve. No patient had any side effects of CNPs from 152 patients followed up for an average of 19.6 months (6-34 months). LNs were easily found under ETBAA. The accuracy of black-dyed LN in thyroid cancers was 95.9% (1016/1059). The number of parathyroid glands passive display was 69.9% (267/382). Conclusions: It is feasible to use CNPs to show CLNs in thyroid cancer during ETBAA. CNP suspension is safe for thyroidal injection.

Clinical utility of routine postoperative morning cortisol monitoring in detecting new hypothalamic-pituitary-adrenal axis insufficiency following endoscopic transsphenoidal surgery for sellar lesions.

Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is a well-documented complication of transsphenoidal craniotomy (TSC) for sellar lesions. The authors aimed to assess their multidisciplinary approach to the diagnosis and treatment of postoperative hypocortisolemia utilizing conservative screening methods. The authors performed a retrospective review of 257 patients who underwent TSC for pituitary adenoma (PA) or Rathke cleft cyst (RCC) at the University of Southern California between 2012 and 2017. Patients with preoperative adrenal insufficiency, Cushing's disease, or < 3 months of postoperative follow-up were excluded. Patient demographics, pathology, tumor characteristics, and complications were recorded. Postoperative day 1 (POD1) morning serum cortisol was assessed in all patients. Hypocortisolemia on POD1 (serum cortisol < 5 μg/dl) prompted a 7 am cortisol level measurement on POD 2 (POD2). Clinical signs and symptoms of hypocortisolemia were consistently monitored. After two serum cortisol levels < 5 μg/dl, or one serum level < 5 μg/dl plus a high clinical suspicion for HPA dysfunction, high-risk patients received glucocorticoid supplementation. Data on 165 patients were included in the analysis; there were 101 women (61.2%) and 64 men (38.7%). Preoperative diagnoses included nonfunctional adenoma (n = 97, 58.7%), growth hormone-secreting adenoma (n = 37, 22.4%), RCC (n = 18, 10.9%), prolactinoma (n = 8, 4.8%), and other (n = 5, 3.0%). One hundred thirty-eight patients (63.0%) had either suprasellar extension or cavernous sinus invasion. POD1 hypocortisolemia was diagnosed in 8 patients (4.8%). Of these patients, 2 (1.2%) were clinically asymptomatic and had normalized POD2 cortisol levels. Six patients (3.6%) had clinical symptoms and POD2 cortisol levels confirming HPA axis deficiency. Of these 6 patients treated with early glucocorticoid replacement, 2 patients recovered HPA axis function during follow-up, making the incidence of new, permanent HPA axis deficiency 2.5%. In the authors' institutional review, all patients warranting postoperative glucocorticoid replacement had both complicated surgical courses and associated clinical symptoms of hypocortisolemia. The authors' algorithm of withholding steroids until patients demonstrate clear evidence of postoperative hypocortisolemia is safe and clinically efficacious. Their data further suggest that routine postoperative cortisol screening may not be necessary following an uncomplicated operative resection, with gland preservation and the absence of clinical symptoms indicative of HPA dysfunction.

P44 Is restoration of pituitary function a realistic goal in endoscopic pituitary surgery?

ObjectivesThe ability to restore pituitary function after endoscopic transsphenoidal surgery (ETSS) in pituitary tumours causing hypopituitarism remains unclear. This study analyses patients that required steroid replacement therapy prior to ETSS, and reviews endocrine function postoperatively.MethodsA prospectively held pituitary database was retrospectively analysed from May 2011 – July 2017 at a tertiary university hospital. Patients requiring steroids for hypopituitarism pre-operatively were included. Patient demographic data, tumour characteristics, and tumour hormonal profile were recorded.ResultsFrom a database of 156 patients, 28 (18%) were hypoadrenal pre-operatively and were included in the study. All patients underwent ETSS by a single neurosurgeon. The median age of patients was 56 years (range 17–81), whilst median follow-up was 48 months (range 6–78). 20 male patients and 8 female patients were included. All patients were established on steroid therapy preoperatively with either hydrocortisone (26 patients) or prednisolone (2 patients). 5 (18%) patients were able to stop steroid replacement postoperatively. The median time to cessation of steroid therapy was 4 months (range 2–16 months).ConclusionsRestoration of pituitary function following ETSS surgery was only successful in a small number of patients despite meticulous gland preservation. Our results suggest that restoration of function in all patients undergoing ETSS is an unrealistic goal and patients should be counselled accordingly.

Complications Associated With Transsphenoidal Pituitary Surgery: Review of the Literature.

Complications Associated With Transsphenoidal Pituitary Surgery: Review of the Literature.

Determinants of level Ib involvement in oral squamous cell carcinoma and implications for submandibular gland-sparing neck dissection

Traditional neck dissection for oral squamous cell carcinoma (OSCC) involves removal of the submandibular salivary gland. Several studies have cited the low incidence of direct gland invasion by tumours and have recommended gland-sparing neck dissection. In this study, a detailed audit of level Ib involvement in OSCC was performed in order to assess the feasibility of submandibular gland-sparing in neck dissection; the rate of direct involvement by the primary tumours, the involvement of periglandular level Ib nodes, and their determinants were investigated. A total of 586 neck dissection specimens obtained between 2005 and 2014 from patients operated on at the study institution for floor of mouth, tongue, and buccal primaries, were evaluated for direct invasion of the gland and periglandular lymphadenopathy. Of 226 node-positive patients, 21 (9.3%) had direct gland invasion by tumour. Risk factors were tumour diameter >4cm (P=0.002) and depth of invasion >10mm (P=0.003). Determinants of periglandular lymphadenopathy were depth of invasion >10mm (P<0.001), perineural invasion (P=0.02), lymphovascular invasion (P=0.014), and moderate/poor differentiation (P<0.0001). Gland-sparing neck dissection is safe in early tumours (pT1pN0–1), with a good chance of minimizing xerostomia without radiotherapy. Larger tumours without clear evidence of submandibular gland invasion or suspicious level Ib lymphadenopathy may be considered for gland preservation, however the oncological safety is unclear.

Advantages of submandibular gland preservation surgery over submandibular gland resection for proximal submandibular stones

This study sought to compare surgical outcomes after the removal of submandibular gland (SMG) stones via 2 different surgical methods. From June 2015 to July 2016, a total of 40 patients with SMG stones were selected from the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University (Shenyang, China), and were randomly assigned to 2 groups. Twenty patients underwent sialendoscopy-assisted stone removal via extraoral incision with preservation of the SMG, and 20 patients underwent traditional SMG resection. The outcomes of the 2 surgical procedures were assessed. The operation time and hospital stay were shorter in the SMG preservation group than the SMG resection group. There were no significant differences in stone size or location between the groups. The mean visual analog scale (VAS) score was lower in the SMG preservation group than the SMG resection group. All patients in the SMG resection group exhibited varying degrees of scarring and concave deformity on the face and neck, whereas all patients in the SMG preservation group retained intact facial morphology. Sialendoscopy-assisted stone removal with preservation of the SMG exhibited many advantages relative to traditional SMG resection.

The use of ICG enhanced fluorescence for the evaluation of parathyroid gland preservation.

Indocyanine green (ICG) enhanced fluorescence imaging is recent innovation as the "real-time intraoperative imaging" technique. Many clinical studies have been reported in the literature which use different devices and techniques that employ various doses and usages of ICG as a non-specific contrast agent. Several groups have performed studies in endocrine surgery, especially with regards to parathyroid-related outcomes after thyroid and parathyroid surgery. However, there is no consensus on the technical details that should be applied. With this study, we aimed to review the current literature on potential use of intraoperative ICG angiography for evaluating parathyroid gland (PTG) preservation.

In situ preservation of the inferior parathyroid gland during central neck dissection for papillary thyroid carcinoma.

Postoperative hypocalcaemia due to dysfunction of the parathyroid glands is the most common complication after total thyroidectomy plus central neck dissection (CND). There is a lack of surgical techniques described to help preserve the inferior parathyroid gland in situ during CND. The objective of this study was to introduce the 'TBP layer' (layer of thymus-blood vessel-inferior parathyroid gland) concept for preserving the inferior parathyroid gland in situ during CND, and to evaluate its effectiveness. The study group included patients with primary papillary thyroid cancer who underwent total thyroidectomy with CND using the new surgical concept between January and December 2014. The control group included sex- and age-matched patients who underwent conventional total thyroidectomy with CND between January 2012 and December 2013. The proportion of inferior parathyroid glands preserved in situ and postoperative hypoparathyroidism rates in the two groups were compared. There were 181 patients in the study group and 306 in the control group. There were no significant differences between the groups in tumour size, multifocality, extrathyroidal extension, and number of harvested and metastatic central lymph nodes. The rate of inferior parathyroid gland preservation in situ was significantly improved from 37·9 to 76·3 per cent on the left side (P < 0·001), and from 52·0 to 77·9 per cent on the right side (P < 0·001), in the study group compared with the control group. The incidence of transient hypoparathyroidism decreased significantly from 35·0 to 7·2 per cent (P < 0·001). Applying the proposed surgical concept improved the rate of inferior parathyroid gland preservation in situ and decreased the incidence of transient postoperative hypoparathyroidism.

Sialendoscopy-assisted transfacial removal of parotid sialoliths: A systematic review and meta-analysis.

To review the literature and conduct a meta-analysis to determine the effectiveness and safety of the combined endoscopic-transfacial approach for parotid sialolith management. PubMed 1946-, Embase 1947-, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, Proquest Dissertations and Theses, and FirstSearch Proceedings to March 2015. Published prospective or retrospective English-language studies with reported outcomes of more than one patient undergoing the combined endoscopic-transfacial procedure for parotid sialolithiasis were included. Two independent authors screened all eligible studies and reviewed and extracted data from relevant publications. Weighted pooled proportions for stone removal, symptom improvement, gland preservation, and complications were calculated. Ten studies, primarily retrospective single-institution studies, were included in the final analysis, with a total of 184 patients. Overall, the procedure was noted to be successful with low risk; the weighted pooled proportions were 0.99 (95% confidence interval [CI]: 0.97 to 1.00) for stone removal, 0.97 (95% CI: 0.93 to 0.99) for symptom improvement, 1 (95% CI: 0.99 to 1.00) for gland preservation, and 0.06 (95% CI: 0.01 to 0.15) for complications. Although our analysis is primarily based on retrospective data, the evidence shown here suggests that the combined endoscopic-transfacial technique is an effective treatment for parotid gland sialolithiasis not amenable to intraoral or purely endoscopic removal. This approach results in high rates of symptom improvement and gland preservation. The complication rates are low, further supporting the use of this technique. Laryngoscope, 127:2510-2516, 2017.

The effect of submandibular gland preservation during level 1B neck dissection on postoperative xerostomia

ObjectiveCompare the presence and degree of postoperative xerostomia following preservation or excision of the submandibular gland (SMG) during level IB neck dissection (ND) without adjuvant radiation. MethodsRetrospective review with patient questionnaire administered to patients with pT1-2N0 oral squamous cell carcinoma (SCC) who underwent resection and ND with SMG preservation or SMG excision without postoperative radiation from 2011 to 2015. We analyzed an additional control group that was age and gender-matched and had not undergone oral resection or SMG excision. We compared the scores reported by the three groups from three questionnaires: University of Michigan Xerostomia Quality of Life (XeQoL), Short Form-8 (SF-8), and a xerostomia severity scale (XSS). Dry mouth severity (DMS) was calculated based on XSS scores among those complaining of any xerostomia. ResultsEleven SMG preservation group, 14 SMG excision group and 15 control group patients completed the survey. Complication and recurrence rates were comparable among experimental groups. No differences were identified between the two experimental groups for the XeQoL, SF-8, and XSS questionnaires (p=0.96, 0.87, 0.7). Control patients reported less xerostomia on XeQoL (p=0.046) and XSS (p=0.01) compared to the experimental groups combined with no statistical difference in SF-8 scores (p=0.25). No patients in either group developed regional recurrence in level IB. ConclusionSMG preservation, though technically and oncologically sound, does not appear in this study to reduce xerostomia. Oral resection with ND may result in some degree of xerostomia perception.

Bilateral Hurthle cell adenoma of thyroid: a rare case report

&lt;p class="abstract"&gt;Hurthle cell of adenoma of thyroid gland is rare neoplasms of the thyroid. Size more than 4 cm is rare finding and moreover the occurrence of a multifocal Hurthle cell adenoma is not supported by antecedents in literature. Sonography fails to identify its potentials for malignancy while fine needle aspiration cytology couldn’t differentiate it from Hurthle cell carcinoma of thyroid. The management of Hurthle cell adenoma and Hurthle cell carcinoma is quite different and hence diagnostic dilemma should be sorted out early. A 26 year old female presented with bilateral thyroid swelling. Ultrasonography of thyroid gland showed complex solid cystic nodules in bilateral thyroid lobes with right thyroid lobe measuring 4.1×3.4×2.5 cm and left thyroid lobe measure 3.1×1.7×1.6 cm. Fine needle aspiration cytology (FNAC) was suggestive of papillary malignancy with extensive Hurthle cell changes (Class V, Bethesda classification). The patient underwent total thyroidectomy with bilateral parathyroid gland preservation. Histopathology revealed it as Hurthle cell adenoma (HCA) involving bilateral lobe and multifocal in nature. The treatment of choice for Hurthle cell carcinoma is total thyroidectomy with neck dissection depending on the nature of the lesions. However the treatment of Hurthle cell adenoma is only hemithyroidectomy or lobectomy as it is a benign condition. Differentiation of these two entirely different conditions warrants more studies&lt;span lang="EN-IN"&gt;.&lt;/span&gt;&lt;/p&gt;

Gland Preservation in Patients Undergoing Sialoendoscopy

Objective Sialoendoscopy is a minimally invasive technique for the treatment of obstructive sialadenitis. We aim to describe treatment considerations and report our ultimate rate of gland preservation. Study Design Case series with chart review. Setting Academic tertiary hospital. Subject and Methods A total of 128 consecutive sialoendoscopy cases for obstructive sialadenitis between 2009 and 2015 were evaluated. Procedures included endoscopic stricture dilation, basket-assisted stone retrieval, Holmium laser lithotripsy, and combined endoscopic transoral stone excision. Resolution of symptoms, need for additional procedures, and rate of subsequent adenectomy were investigated. Results Sialoendoscopy was completed in 120 of 128 patients (94%). There were 87 parotid gland cases and 41 submandibular gland cases. Endoscopic stricture dilation was attempted in 97 patients and successful in 99%. A sialolith was identified in 31 cases and removed by basket-assisted stone retrieval (10 cases), Holmium:YAG laser stone fragmentation (10 cases), and combined endoscopic transoral stone extraction (4 cases). In 8 cases overall, sialoendoscopy failed, with immediate adenectomy. At a mean follow-up of 18 months, 39 patients (33%) reported recurrence of symptoms, with 90% in the stricture group. For the entire cohort, gland preservation occurred in 112 of 128 patients (88%). Conclusions Sialoendoscopy is an effective technique, with few patients requiring additional procedures. Newer interventional approaches allow for stone retrieval without adenectomy. Patients in the stricture group were more likely to have recurrent symptoms as compared with the sialolithiasis group but often benefit from additional sialoendoscopic procedures, leading to a high overall rate of long-term gland preservation of 91%.

Comparison between Sialendoscopy and Conventional Methods in the Treatment of Sialolithiasis.

Sialendoscopy is gaining in popularity in treating calculus disease. The delicacy of the instrument and the diameter of the salivary ducts are factors that limit the ability to achieve complete success. There is also continued speculation regarding the utility of the procedure, especially among clinicians who are masters of conventional methods like sialadenectomy and sialodochotomy. To assess the efficacy of sialendoscopy over conventional methods in treating sialolithiasis. A prospective case control study was conducted in a tertiary care centre; this study involved 50 patients of sialolithiasis, and it extended over a 36-month period. All had undergone treatment, either by conventional methods or interventional sialendoscopy. All patients with nonpalpable calculi smaller than 6 mm underwent interventional sialendoscopy. Failed sialendoscopies and larger nonpalpable calculi were removed through sialadenectomy. The outcome variables studied included calculus removal, postoperative symptoms, and gland preservation. The success rate in terms of calculus removal by sialendoscopy was 88%, versus 100% by sialadenectomy. The salivary gland was preserved in 88% of the cases in the sialendoscopy group. Only 12% of patients were symptomatic. Sialendoscopy was effective in removing calculi of various sizes; it was definitely superior to conventional methods. Sialadenectomy should be reserved for cases either not suitable for sialendoscopy or in which there was an intervention failure.

Gland preserving surgery in paediatric proximal submandibular sialolithiasis: preliminary results in a tertiary centre

Introduction: Around 3% of sialolithiasis occur in children. When these are small and in the distal submandibular duct they can be simply managed by sialendoscopy or by a simple intra-oral release. Proximal sialoliths are much more challenging and historically have been managed by submandibular gland excision. In adults, the current concept is to perform an intra-oral stone release for proximal stones, a more technically difficult but a gland preserving procedure with much less risks and associated morbidity. We have applied this principle in the paediatric patient and have successfully carried out intra-oral stone release for proximal submandibular sialoliths in eight children. We report our prelimimary clinical and patient satisfaction outcomes.

Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society.

Introduction Neck dissection (ND) technique preferences are not well reported. Objective The objective of this study is to educate practitioners and trainees about surgical technique commonality and variance used by head and neck oncologic surgeons when performing a ND. Methods Online survey of surgeon members of the American Head and Neck Society (AHNS). Survey investigated respondents' demographic information, degree of surgical experience, ND technique preferences. Results In our study, 283 out of 1,010 (28%) AHNS surgeon members with a mean age of 50.3 years (range 32–77 years) completed surveys from 41 states and 24 countries. We found that 205 (72.4%) had completed a fellowship in head and neck surgical oncology. Also, 225 (79.5%) respondents reported completing more than 25 NDs per year.ND technique commonalities (>66% respondents) included: preserving level 5 (unless with suspicious lymph nodes (LN)), only excising the portion of sternocleidomastoid muscle involved with tumor, resecting lymphatic tissue en bloc, preservation of cervical sensory rootlets, not performing submandibular gland (SMG) transfer, placing one drain for unilateral selective NDs, and performing a ND after parotidectomy and thyroidectomy and before transcervical approaches to upper aerodigestive tract primary site. Variability existed in the sequence of LN levels excised, instrument preferences, criteria for drain removal, the timing of a ND with transoral upper aerodigestive tract primary site resections, and submandibular gland preservation. Results showed that 122 (43.1%) surgeons reported that they preserve the submandibular gland during the level 1b portion of a ND. Conclusions The commonalities and variances reported for the ND technique may help put individual preferences into context.

Salivary gland-sparing helical tomotherapy for head and neck cancer: Preserved salivary function on quantitative salivary gland scintigraphy after tomotherapy

GoalsProspective evaluation of salivary gland preservation, overall survival and local recurrence-free survival after head and neck cancer treated by helical tomotherapy (HT). Material and methodsFrom March 2007 to February 2009, 30 patients with head and neck cancer were treated by HT. The salivary excretion fraction (SEF) was assessed by technetium salivary gland scintigraphy before, and 6, 12 and 18 months after HT to define salivary gland preservation rates. Patients were reviewed every 3 months to assess clinical toxicity. ResultsThe median follow-up was 4.3 years. The mean dose to the ipsilateral parotid gland (IPG) was 25.4Gy. Good preservation of parotid gland function was observed in 84% of the 19 patients evaluated by scintigraphy at 18 months. The 5-year local recurrence-free survival (LRFS) was 100% among the 6 patients who received a dose of more than 26Gy to the parotid gland. The 28-month LRFS was 33% in the group that received a dose of less than 20Gy versus 91% in the group that received a dose of more than 20Gy to the IPG. ConclusionsHelical tomotherapy reduced the incidence and severity of xerostomia. A mean dose to the parotid between 20 and 26Gy allowed preservation of salivary function without compromising treatment efficacy. However, parotid-sparing HT requiring a mean dose less than 20Gy is associated with an increased risk of recurrence.

Prospective study of the pattern of lymphatic metastasis in relation to the submandibular gland in patients with carcinoma of the oral cavity.

The submandibular gland is responsible for 70% to 90% of unstimulated saliva production. Its excision causes a decrease in basal salivary flow resulting in increased symptoms of subjective xerostomia and decreased quality of life. In this study, we have tried to assess the pattern of nodal metastasis in relation to the submandibular gland. With this study, we have tried to find out whether submandibular gland preservation is a viable option in patients with carcinoma of the oral cavity. This was a prospective study conducted in a tertiary care cancer center. The fibrofatty tissue surrounding the submandibular gland was divided into 6 parts depending upon its location with the submandibular gland. All these 6 parts along with the submandibular gland were separately sent for histopathological analysis. Metastasis pattern in level Ib region was noted. The study included 137 patients with carcinoma of the oral cavity who underwent neck dissections. Eighty-five patients had clinic-radiologically N0 neck, 52 patients had cN+ (clinically node positive) neck. Level Ib was involved in 8.2% of the cases with cN0 (clinically node negative neck). In patients with cN+ neck, level Ib metastasis was seen in 40% of the cases. Metastasis in N0 necks in the area deep to the submandibular gland was seen in only 1 case (9% of all pathologically node-positive patients) with cN0 neck. This was the only case in which submandibular gland mobilization would have been required to take out the metastatic node. Even in cases with N+ neck, deep metastasis was seen in 4 cases only (14.8%). None of them had a primary tumor in the tongue. Therefore, there is a possibility of preserving the submandibular gland in cases of carcinoma of the tongue. Involvement of level Ib in early tongue cancers is not very common and direct metastases to the submandibular glands are rare. Even when metastasis is present in level Ib, it can be excised without affecting the submandibular gland. In early tongue lesions, submandibular gland mobilization for dissection at level Ib is not required as no metastases deep to the submandibular glands were seen in these patients. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

The introduction of sialendoscopy has significantly contributed to a decreased number of excised salivary glands in Denmark.

Excision has been the treatment of choice in benign non-tumorous obstructive disorders of the major salivary glands, when symptoms persisted in spite of conservative measures. Unfortunately surgical resection has been associated with a relatively high rate of adverse effects. To meet the need for a less invasive treatment modality for benign obstructive non-tumorous disorders (i.e., salivary stones or stenosis), sialendoscopy has been developed and implemented in several countries here among Denmark. This study is a 13-year retrospective registry-based study using The Danish National Patient Register. ICD-10 codes used for non-tumorous obstructive disease of the salivary glands were identified and used to extract patients potentially eligible for sialendoscopy in order to compare sialendoscopic surgery and extirpations of salivary glands. In 2012 sialendoscopy accounted for almost 20% of all surgical interventions on the major salivary glands due to benign non-tumorous disease. Nationally and regionally the total number of resected major salivary glands due to benign obstructive disease also decreased significantly during the study period. A positive outcome, like the ones described here, will inspire further development and dissemination of gland preserving techniques, to great benefit for the patients.