Submandibular Gland Resection Research Articles

Feasibility of robot‐assisted submandibular gland resection via retroauricular approach: Preliminary results

To present the surgical technique and feasibility of robot-assisted submandibular gland (SMG) resection via retroauricular approach. Feasibility study of case series. We performed robot-assisted SMG resection on five patients with benign SMG tumors. The surgical complications, operation time, amount of bleeding, amount and duration of drainage, and duration of hospital stay were reviewed. The surgery was successful in all patients without any significant complications. The mean operation time was 62.4 ± 6.3 minutes, amount of bleeding was 10.4 ± 3.2 mL, amount of drainage was 149.8 ± 114.7 mL (3.2 ± 1.6 days), and duration of hospital stay was 4.2 ± 1.8 days. All patients showed excellent cosmetic satisfaction because the postoperative scar was hidden by the auricle and hair. Robot-assisted SMG resection was feasible without any significant complications and satisfactory cosmetic results. The safety and oncologic outcome of the procedure should be verified with larger number of patients and longer follow up period.

Late Solitary Metastasis of Renal Cell Carcinoma to the Submandibular Gland

Metastatic renal cell carcinoma to the head and neck is rare. Most reported cases of metastases to the head and neck involve the thyroid and parotid glands. Metastasis to other salivary glands is exceedingly rare. This report describes a case of a solitary metastasis of renal cell carcinoma to the submandibular gland 9 years after nephrectomy. To the authors' knowledge, this is the first case successfully diagnosed preoperatively using a combination of fine-needle aspiration and clinical history. The patient subsequently underwent a submandibular gland resection with preservation of the facial nerve branches. For the 3 years since resection of the submandibular gland, the patient has been free of disease.

Salivary VEGF Plays an Essential Role in Oral Mucosal Wound Healing

Introduction: Palatal mucosal wound healing occurs more rapidly than in cutaneous wounds. Vascular endothelial growth factor (VEGF) induced angiogenesis is critical for cutaneous wound healing. We have previously demonstrated 1) salivary glands produce high levels of VEGF and 2) an essential role for salivary VEGF (salVEGF) in the intestinal response to injury. This has led us to hypothesize that salVEGF is critical in oral mucosal wound healing and neovascularization. to test this hypothesis, we performed a loss-of-function experiment by selectively inhibiting salVEGF using a novel adenoviral construct (AdVegfTrap) and a gain-of-function experiment by supplementing oral VEGF following submandibular gland (SMG) resection. Methods: In the loss-of-function experiment, C57/BL6 mice underwent SMG duct cannulation and were treated with 1x108 PFU AdVegfTrap, AdLacZ or PBS (n=5/group). 1.5 mm palatal mucosal wounds were created. in the gain-of-function experiment, C57/BL6 mice underwent SMG sialoadenectomy (n=4) or sham operation (n=5). 1.5 mm palatal wounds were created and oral VEGF protein was supplemented. AdVegfTrap was not used due to anticipated consumption of the orally replaced VEGF. in both experiments, salVEGF protein levels were quantified by ELISA. Wounds were harvested at 3 days and analyzed for epithelial gap and vessel density. Data were expressed as mean+SEM. Results: Retrograde SMG duct injection of AdLacZ results in 100% transduction efficiency confirming effective transgene delivery. SMG duct cannulation, SMG administration of AdLacZ and sham operation controls do not result in significantly decreased of salVEGF (PBS513pg/ml±141 vs AdLacZ353pg/ml±56 vs sham472pg/ml±40 vs control514pg/ml±89;p=NS). Administration of AdVegfTrap results in depletion of salVEGF comparable to SMG sialoadenectomy (AdVegfTrap122pg/ml±42 vs SMG resection136pg/ml±15.9;p=NS). Selective inhibition of salVEGF by AdVegfTrap impairs wound closure (AdVegfTrap947μm±22 vs AdLacZ411μm±21 vs PBS355μm±31;p<0.001) and vessel density (AdVegfTrap15.95caps/hpf±0.83 vs AdLacZ30.87caps/hpf±1.1 vs PBS30.5caps/hpf±0.95;p<0.001). Oral replacement of VEGF in SMG resected mice rescues the impaired reepithelialization and neovascularization phenotype (SMG with oral VEGF194μm±43 vs sham350μm±46,p=NS; SMG with oral VEGF24.0caps/hpf±1.4 vs sham18.6caps/hpf±2.1,p=NS). Conclusions: Selective inhibition of salVEGF significantly impairs palatal reepithelialization and neovascularization. Oral supplementation of VEGF rescues the impaired wound healing phenotype in SMG sialoadenectomized mice. Taken together, these findings suggest that salVEGF is an essential growth factor in oral mucosal wound healing which may be a surrogate for intestinal wound healing. the palatal wound model may be a valuable tool in understanding the critical role of salVEGF in the alimentary tract response to injury.

Retrograde Sialendoscopy: A New Technique for Avoiding Retained Ductal Stones

Recurrent infection from stones retained in Wharton's duct after submandibular gland resection warrants intraoperative attention to the duct remnant. Our hypothesis was that retrograde sialendoscopy would help ensure complete stone removal in submandibular gland removal for sialolithiasis. We reviewed 9 sequential cases of submandibular sialolithiasis treated surgically via open procedures at a tertiary care center by a single surgeon between November 2007 and December 2009. The review focused on the clinical history and intraoperative findings. We identified successful application of a new technique of retrograde sialendoscopy performed to detect and remove stones that were retained in Wharton's duct at the time of submandibular gland resection. An index case of complications from a stone retained after submandibular gland resection is presented in a sequential series of cases in which retrograde sialendoscopy was developed. Retrograde sialendoscopy is a novel technique that is useful as an adjunct to standard submandibular gland resection in the management of sialolithiasis.

A Case of Oncocytic Carcinoma Arising in the Submandibular Gland

Oncocytic neoplasm of the head and neck region accounts for approximately 1% of all salivary gland tumors, but only 5% of oncocytic neoplasm is malignant. Oncocytic carcinoma arising in the submandibular gland is exceedingly rare. We encountered a sixty seven-year-old male patient who presented with multiple mass in the right neck. Fine needle aspiration biopsy revealed a salivary gland tumor of predominantly oncocytic form, and a differential diagnosis included oncocytic adenoma or mucoepidermoid carcinoma. A right submandibular gland resection and modified radical neck dissection were performed. Histologically, the tumor cells showed nuclear pleomorphism, and stromal invasion, which were compatible with oncocytic carcinoma. After surgery, the entire neck region was irradiated. Seventeen months after the initial surgery, multiple metastases to the bone and lung were detected from the incidental pathologic bone fracture of the right humerus; palliative chemotherapy was performed to resolve this. We report a case of oncocytic carcinoma in the submandibular gland with a review of literature.� Korean J Otorhinolaryngol-Head Neck Surg 2012;55:173-6 Key WordsZZSubmandibular gland neoplasms ㆍLymphatic metastasis.

顎下腺に発生した基底細胞腺腫の1例

Basal cell adenoma （BCA） was added to the classification of salivary gland tumors by the WHO in 1991. BCA occurs most frequently in the parotid glands, and BCA of the submandibular glands is relatively rare. We report our experience with BCA arising in the submandibular gland. A 73-year-old man was referred to our department because of a swelling in the right submandibular region. Physical examination revealed a round, hard mass, about 35 mm in diameter, in the submandibular region. On CT, MRI, and US studies, we found a well-circumscribed mass. On the basis of clinical findings, the diagnosis was a benign tumor of the right submandibular gland. Under general anesthesia, resection of the right submandibular gland was performed. Histopathologically BCA is classified into four types: tubular type, trabecular type, and membranous type, and solid type. The most common is solid type. The present case was solid-trabecular mixed type.On postoperative follow-up for 12 months, the patient has remained well without any further abnormal findings or signs of tumor recurrence on clinical examinations to date.

Metastatic adenoid cystic carcinoma of the salivary gland responding to cetuximab plus weekly paclitaxel after no response to weekly paclitaxel alone

Adenoid cystic carcinoma (ACC) of the salivary gland frequently develops lung metastases. In cases in which chemotherapy is indicated, resistance is a common phenomenon. New drugs, such as cetuximab, have been chosen to avoid this chemoresistance. A 54-year-old man was diagnosed with ACC of the right submandibular gland. He underwent a submandibular gland resection with adjuvant radiotherapy. Three years later, bilateral lung metastases were diagnosed and treated with various chemotherapy schedules, including paclitaxel without success. We obtained radiographic response, followed by disease stabilization for more than 1 year with the addition of cetuximab to paclitaxel administered at low weekly doses (metronomic schedule). This case demonstrates for the first time a reversion of primary resistance to chemotherapy in ACC that is currently considered chemoresistant by use of a combination of metronomic chemotherapy with new targeted agents such as cetuximab. Metronomic chemotherapy was also well tolerated and achieved long-term response.

Advantages of intraoral removal over submandibular gland resection for proximal submandibular stones

To compare surgical outcomes after intraoral removal of proximal submandibular stones versus traditional submandibular gland (SMG) resection. : A prospective randomized study. Forty-four consecutive patients were diagnosed with proximal submandibular stones in the hilum of the submandibular gland by ultrasonography or computed tomography. All of the patients were randomized to undergo removal of the stones either by an intraoral approach (IORS group, 22 patients) or through SMG resection (SMGR group, 22 patients). We then compared the surgical outcomes between these two groups. Stones in the IORS group were significantly smaller than those in the SMGR group. There was no significant difference in the distance of the stones from the hilum between groups. The mean operation time in the IORS group was significantly shorter than that of the SMGR group. The mean hospital stay of the IORS group was also significantly shorter than that of the SMGR group, and IORS patients felt significantly less pain than did SMGR patients. No patient experienced any complication after surgery with the exception of a single patient who experienced transient and mild neck swelling. Intraoral removal of proximal submandibular stones has several advantages over SMG resection. Based on our results, we suggest that our intraoral removal method be selected as the primary procedure for the removal of proximal submandibular stones rather than SMG resection.

Endoscope assisted submandibular sialadenectomy: the face-lift approach

This study evaluated the benefits of a new approach, endoscopic resection of a submandibular gland through the face-lift approach. The study comprised the clinical trial of new procedure. Six submandibular sialadenectomies were carried out (4 women, 2 men; mean age 28 years) via the face-lift approach by endoscopy. All six submandibular gland resections were successfully performed endoscopically, and no conversion to conventional open resection was necessary. Five patients had a mixed tumor and one patient had sialadenitis. The procedures lasted 55-115 min (mean 74 min). No complications associated with the operation occurred, and the scar was almost invisible. Endoscope assisted submandibular sialadenectomy via the face-lift approach was safe and effective treatment of benign lesions. The main advantage of this procedure is that the operative scar is concealed by the hairline.

Endoscopic resection of the submandibular gland via a hairline incision: A new surgical approach

Submandibular gland excision is traditionally performed by the transcervical approach. To avoid or reduce visible scarring and nerve injury, diverse innovative surgical trials have been reported. Here we report a patient who had an endoscopic submandibular gland resection via a hairline incision. A 36-year-old woman presented with a right submandibular gland tumor that was found on a routine check-up. The submandibular gland was resected under endoscopic assistance via a posterior hairline incision using an ultrasonic scalpel. The resection was successful, causing no acute complications, such as neural injury, hematoma, or seroma formation. The incision scar healed with an excellent cosmetic result. Endoscopic submandibular gland resection via a hairline incision was feasible and resulted in an excellent surgical and cosmetic outcome. Laryngoscope, 2010.

Impact of submandibular gland excision on salivary gland function in head and neck cancer patients

Head and neck cancer surgery is often associated with neck dissection and usually includes the submandibular glands. Literature data related to remaining salivary gland function after surgery is scarce and controversial. A reduction in salivary output and increase in complaints of xerostomia have been suggested. However, a compensatory salivary mechanism has also been reported. The aim of this prospective study was to evaluate the effect of neck dissection (with submandibular excision) on salivary gland function measured by salivary flow rate and salivary gland scintigraphy. A total of 80 patients with head and neck tumors were evaluated. The surgery group was composed of 37 patients, who underwent submandibular gland resection, and the non-surgery group of 43 patients evaluated prior to radiation and/or chemotherapy treatment. Whole unstimulated and stimulated saliva collection and salivary gland scintigraphy were performed in all patients. Twenty-one percent of patients in the surgery group reported xerostomia, whereas 7% in the non-surgery group. The mean unstimulated salivary flow was 0.60 and 0.94 m/min for the surgery and non-surgery groups, respectively (p=0.008). Nevertheless, no statistical difference in the stimulated salivary flow was observed between the groups (p=0.26). In addition, the mean uptake and excretion rates for parotid and remaining submandibular glands also showed no statistical difference. The data of the present study support the contention that submandibular gland resection causes a decrease in unstimulated salivary volume. However, the residual submandibular glands in the surgery group showed similar function to that of submandibular glands in the non-surgery group. Consequently, the compensatory salivary mechanism seems not to be a possibility.

Removal of the Submandibular Gland Using a Combined Retroauricular and Transoral Approach

To evaluate the feasibility and outcome of a combined retroauricular and transoral approach for removing the submandibular gland. Thirteen patients underwent removal of benign submandibular gland lesions (6 sialoadenitis with sialolithiasis, 4 chronic sialoadenitis, and 3 pleomorphic adenomas) using a combined retroauricular and intraoral approach. All 13 submandibular sialoadenectomies were successful and all of the wounds healed uneventfully. A temporary deficit of the lingual nerve developed in 2 cases and mild limited movement of the tongue developed in 3 cases. No patient suffered from weakness of the marginal mandibular branch of the facial nerve. The follow-up averaged 14.1 months (range, 6-24 months); no tumors recurred. The incision scars were invisible. Submandibular gland resection using a combined retroauricular and transoral approach is a feasible method for benign submandibular gland lesions that provides an acceptable cosmetic outcome.

The use of cyanoacrylates for wound closure in head and neck surgery

The purpose of this study was to compare the mean duration and complication rates of cyanoacrylate application in head and neck incision closures to those performed with conventional sutures. Eighty patients who underwent head and neck surgical operations (20 thyroidectomies, 13 submandibular gland resections, 9 parotidectomies, 6 neck dissections in conjunction with other surgical procedures, 1 lateral rhinotomy, 1 thyroglossal cyst resection and 30 open neck biopsies) were included in the study. The incisions were closed either with interrupted suture technique (32 patients) or cyanoacrylate (48 patients). The duration of skin closure time was compared between the two groups with nonparametric Mann-Whitney U test and a P value <0.05 was considered as statistically significant. The patients were followed up for complications at 2 weeks, 1 and 3 months after surgery. The two treatment groups were similar with respect to age, gender, and wound lengths (P = 0.27, 0.22 and 0.99, respectively). The mean wound length was 7.21 + 3.15 cm in the cyanoacrylate group and 7.22 + 2.99 cm in the suture group within a range of 5-15 cm. The mean closure time was 33.69 + 9.77 s in the cyanoacrylate group and 504.38 + 169.27 s in the suture group (P < 0.001). The patients in the cyanoacrylate group were satisfied with their scar appearances. No complication was observed in both the groups. Cyanoacrylates provide an easy and convenient application resulting in a faster wound closure as compared to the interrupted suture technique.

Removal of the submandibular gland by a submental approach: A prospective, randomized, controlled study

There are few controlled studies on surgical approaches for excision of the submandibular gland (SMG). This study evaluated the benefits of a submental approach, compared with a conventional submandibular approach, for SMG resection. Twenty patients with benign SMG disorders, 12 with pleomorphic adenoma and eight with chronic sialadenitis with sialolithiasis, were resected using a submental (10) or submandibular (10) approach. The submental approach consisted of a horizontal incision on the submental skin and flap elevation to the gland, and the submandibular approach consisted of an incision along the skin crease overlying the SMG. Operation time, complications, hospital stay, cosmetic appearance and subjective satisfaction with the incision scar were compared between groups. The two groups were well matched in age, gender, marital status, and SMG disorders. Mean operation time, hospital stay and complication rates were comparable in the 2 groups. Mean patient satisfaction score was higher in the submental than in the submandibular group (8.8 vs. 5.4, P=.01), and the incision scar in the submental group was usually less visible. Compared with the submandibular approach, the submental approach can provide better cosmetic outcomes with no increases in operation time and complication rates.

Minimally invasive endoscopic resection of the submandibular gland: A new approach

This study evaluates the benefits of a new approach, endoscopic resection of the submandibular gland through the hyoid midline level skin incision by use of an ultrasonically activated scalpel. Twelve operations for patients presenting with submandibular gland disease were performed via minimally invasive endoscopic resection by a single surgeon (M-KC). All 12 submandibular gland resections were successfully performed endoscopically, and no conversions to conventional open resection were necessary. Of the 12 patients who underwent excision, 3, 6, and 3 had mixed tumor, sialoadenitis with sialolithiasis, and chronic sialoadenitis, respectively. The procedures lasted 50 to 125 minutes (median duration, 70 minutes). No complications associated with the operation occurred, and the scar was almost invisible because of its concealed location with the neck in the natural position. Endoscopic resection of the submandibular gland is a feasible method for treatment of benign lesions. The main advantages of this procedure are that the small operative scar is concealed in the submental skin crease, resulting in improved cosmetic results and minimization of the possibility of facial nerve injury.

Aesthetic surgery – pertinent papers 2002–2003: A personal view

Aesthetic surgery – pertinent papers 2002–2003: A personal view

Senile chronic submandibular sialadenitis

To evaluate the clinic characteristic and treatment of senile chronic submandibular sialadenitis. The clinical records of the patients over 50 years old whose final diagnosis was chronic submandibular sialadenitis were reviewed. The patients were diagnosed as neoplasm of submandibular gland before operation, There was no radiographic sign of sialolithiasis, no clinical and laboratory signs of Sjögren syndrome or related autoimmune disease. Thirty-five patients were presented in masses in the submandibular space, which was not related to eating. Histopathologic study showed destruction of acinus, infiltration of inflammatory cell, and micro-calcification in the intercalated duct. The diagnosis of senile chronic submandibular sialadenitis should be considered if a mass in the submandibular space occurs in the old patients and radiographic study shows no sialolithiasis and neoplasm. Resection of the submandibular gland is not necessary for these patients.

Submandibular gland endoscopic resection: acadaveric study

Recent advancement of head and neck surgery has been marked by the development of endoscopic and video-assisted minimally invasive surgery. This study reports the feasibility of endoscopic submandibular gland resection in human cadavers. Twelve submandibular gland resections were performed in six human cadavers. A 30° angle endoscope and conventional surgical instruments were inserted through two 15 mm submandibular incisions. Dissection was carried out bluntly with scissors in an avascular plane superficial to the gland. No insufflation was needed since transcutaneous sutures lead to effective retraction. Facial vessels, the lingual nerve and Wharton's duct were identified and protected. Vascular ligatures were performed using surgical miniclips. After the procedure, an open submandibular dissection was performed to control the integrity of the anatomical structures. In all cases, the resection of the submandibular gland was successful without the need for an additional incision. Injuries of the facial artery and lingual nerve occurred when the procedure was carried out initially. The operative time decreased with training, from 120 min for the first cases to 35 min for the later ones. In conclusion, endoscopic submandibular gland resection is possible without major difficulty. Training and experience reduce the operative time and the complication rate.

Endo-robotic resection of the submandibular gland in a cadaver model

By means of a prospective, nonrandomized investigation, we evaluated the feasibility of performing endo-robotic resection of the submandibular gland in a cadaver model and compared the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique. Procedural times were recorded in a consecutive series of 11 endoscopic submandibular gland resections using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) and a modified endoscopic surgical approach previously developed in a porcine model. The presence of neurovascular injury was assessed postoperatively, and the specimens were examined histologically. Eleven endo-robotic submandibular gland resections were successfully performed in six cadavers (no conversions to open resection were necessary). The median duration of the procedures was 48 minutes (range, 33-82 minutes). Creation of the operative pocket took an average (+/-SD) of 12.2 +/- 5.3 minutes, assembly of the robot required 9.3 +/- 4.1 minutes, and the mean time for submandibular gland resection was 29.4 +/- 8.9 minutes. The time required for robotic assembly was offset by the reduced operative time necessary compared with conventional endoscopic resection. Histologic examination confirmed the presence of normal glandular architecture, without evidence of excessive mechanical or thermal injury. There were no cases of apparent neurovascular injury. Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.

Endoscopic neck surgery: resection of the submandibular gland in a cadaver model.

The objective was to evaluate the feasibility of performing a totally endoscopic resection of the submandibular gland in a cadaver model. Prospective, nonrandomized experimental investigation in a cadaver model. A modified endoscopic surgical approach (representing a hybrid of balloon dissection and low-pressure carbon dioxide insufflation) previously developed in a porcine model was implemented in fresh cadavers. Once a reliable protocol was achieved, eight procedures were performed in six cadavers. Data collected prospectively included the operative time, inadvertent neurovascular injury, and size of the glands. All eight endoscopic submandibular gland resections were successfully performed in six consecutive cadavers (no conversions to open resection were necessary). The duration of the procedures ranged from 50 to 150 minutes, with a median duration of 65.5 minutes and a steady trend toward a shorter duration. Histological examination confirmed the presence of normal glandular architecture without evidence of excessive trauma or thermal injury. The optimal spacing of the instrument ports was 4 cm from the camera port. There were no cases of neurovascular injury. In two cadavers, a minimal amount of subcutaneous emphysema could be appreciated, which was limited to the skin overlying the dissection. Totally endoscopic resection of the submandibular gland is possible by combining balloon dissection with low-pressure carbon dioxide insufflation. The excellent visualization afforded by the endoscope provided a safe operative approach. Ultimately, a number of endoscopic neck procedures may be possible, and clinical trials are under way.