Submandibular Gland Transfer Research Articles

PO-1196 Submandibular gland transfer to preserve salivary function: a prospective study of 16 HN patients

PO-1196 Submandibular gland transfer to preserve salivary function: a prospective study of 16 HN patients

Submandibular gland transfer for the prevention of radiation-induced xerostomia in oropharyngeal cancer: Dosimetric impact in the intensity modulated radiotherapy era.

Submandibular gland (SMG) transfer decreased radiation-associated xerostomia in the 2/3-dimensional radiotherapy era. We evaluated the dosimetric implications of SMG transfer on modern intensity modulated radiotherapy (IMRT) plans. Eighteen oropharynx cancer patients underwent SMG transfer followed by IMRT; reoptimized plans using the baseline SMG location were generated. Mean salivary gland, oral cavity, and larynx doses were compared between clinical plans and reoptimized plans. No statistically significant difference in mean SMG dose (27.53 Gy vs. 29.61 Gy) or total salivary gland dose (26.12 Gy vs. 26.41 Gy) was observed with or without SMG transfer (all p > 0.05). Mean oral cavity and larynx doses were not statistically different. Neither tumor site, target volume crossing midline, stage, nor salivary gland volumes were associated with mean doses. Salivary gland doses were similar with or without SMG transfer. IMRT likely decreases the benefit of SMG transfer on the risk of radiation-associated xerostomia.

Submandibular Gland Transfer for the Prevention of Radiation Induced Xerostomia in Head and Neck Cancer — Dosimetric Impact With Intensity Modulated Radiotherapy

Post-radiation xerostomia is an important toxicity of head and neck radiotherapy, contributing to decreased quality of life and other adverse effects. Submandibular gland (SMG) transfer prior to radiation previously demonstrated a statistically significant benefit in xerostomia reduction in the 2/3 dimensional treatment era. In the procedure, the SMG is transposed anteriorly to the submental space. In patients receiving radiation to the level II but not level IB neck, this displacement removes the SMG from the treatment portal, thereby preserving gland function. Herein we evaluate the dosimetric implications of SMG transfer on intensity modulated radiotherapy (IMRT) treatment plans.We conducted a retrospective review of oropharynx cancer patients who underwent SMG transfer surgery followed by curative IMRT at our institution. Pre-surgery computed tomography (CT) scans had previously been fused with the planning CT. Separate scans were fused to the planning CT for 5 patients who had not had previous fusions. Pre-surgery SMG glands were contoured. Dose to the pre-surgery SMG was assessed on the treated clinical plan (TCP). A new plan (NP) was then generated, optimizing based on the pre-surgery SMG. Dosimetry attempted to meet all standard institutional constraints and match the salivary gland mean doses of the TCPs. Mean salivary gland, oral cavity, and larynx doses were collected. We evaluated the differences in plan outcomes using t-tests.18 patients with median age 61.5 years (range 25-74) underwent SMG transfer between 2019 and 2021 (94.4% male and 94.4% received concurrent cisplatin). Mean SMG dose and mean total parotid and SMG gland (TPSG) dose post-transfer was 27.5 Gy and 26.1 Gy (standard deviation (SD) 6.9 and 3.3), respectively; pre-transfer SMG and TPSG mean dose was 40.4 Gy and 27.8 Gy (SD 9.4 and 3.5) and 29.6 Gy and 26.4 Gy (SD 7.7 and 3.9) in TCPs and NPs, respectively. Differences between pre- and post-transfer SMG and TPSG doses in TCPs were statistically significant, as were differences between pre-transfer SMG and TPSG doses in TCPs versus NPs (all P < 0.001). Differences between pre-transfer NP and post-transfer TCP doses were not statistically significant (P > 0.1). Mean oral cavity and larynx doses were 32.9 Gy and 31.4 Gy (SD 6.8 and 9.9) and 33.5 Gy and 30.8 Gy (SD 7.5 and 9.6) in TCPs and NPs, respectively (all P > 0.1).SMG mean dose was lower by ∼2 Gy in TCPs relative to the non-transferred SMG mean dose in reoptimized NPs, although this difference did not reach statistical significance. Inverse planning likely decreases the benefit of SMG transfer to reduce the risk of xerostomia. More investigation is needed to evaluate if patient subsets would benefit more than others based on tumor location (tongue base versus tonsil) and treatment modality (proton versus photon).

Dosimetric, Volumetric, and Positional Stability After Submandibular Gland Transfer

Xerostomia and its effects are significant challenges for patients receiving radiation therapy (RT) for head and neck cancers (HNC). Submandibular gland (SMG) transfer has demonstrated promise in reduction of subjective and objective xerostomia. However, SMG transfer investigations have largely employed conventional RT or adjuvant RT, with little evaluation in patients treated with definitive modern RT. Furthermore, there has been no assessment of whether anatomic changes during RT may affect the potential benefits of SMG. We sought to characterize the preliminary dosimetric, volumetric, and positional stability of SMG transfer on an ongoing prospective case-control study.Previously untreated patients with oropharyngeal HNC, N0-N2b (unilateral neck disease) were enrolled. SMG transfers were performed by experienced surgeons per the Jha and Seikaly technique, transposing the gland anteriorly into the submental neck. Definitive VMAT plans were optimized according to institutional guidelines (goal mean SMG dose < 26 Gy), patients were treated to 70 Gy in 33-35 fractions. To assess the stability of planned dose and change in SMG volume and position, repeat CT simulation was performed at week 4. These were rigidly registered to the initial simulation centered about the mandible and hyoid, with the original dose superimposed. Glands were meticulously re-contoured on both scans. Statistical comparisons were by Wilcoxon paired rank tests or Mann-Whitney U tests.To date, 11 patients with SMG transfer and 5 controls have been treated, all male. In 3 cases, no re-simulation was available and a week 4 cone-beam CT was used. The mean time from gland transfer to RT start was 28.3 days. From simulation to week 4, transposed SMGs shrunk by a mean of 3.49 cc (27.6%), no different than corresponding contralateral SMGs at 2.37 cc (23.5%) or control SMGs (SMGs in control patients on the N0 side) at 1.71 cc (22.8%). There were no associations between SMG volume change and dose by linear regression or Spearman's rank correlation. Transposed SMGs had an average mean dose of 28.2 Gy on initial sim. At week 4, extrapolated to a full course, this increased to 32.8 Gy (P = 0.01). Average mean dose to control glands was 46 Gy, statistically greater than transposed glands (P = 0.03), with a non-significant 1.5 Gy increase at week 4. Mean change in geometric position was 0.45 cm for transposed glands, 0.37 cm for contralateral glands (P = .19), and 0.32 for control glands (P = .37).SMG transfer achieved significant reduction in dose compared to controls. While SMG shrinkage and movement were not separately different from contralateral or control glands, the higher dose at re-simulation indicates these factors may together have an effect, calling for careful SMG delineation, attention to daily position and image guidance, and planned re-simulation in order to maximize dosimetric benefits. Our trial is ongoing and clinical and QoL endpoints will be examined with these findings in mind.

Modified technique of submandibular gland transfer followed by intensity modulated radiotherapy to reduce xerostomia in head and neck cancer patients.

Xerostomia is one of the most common long-term adverse effects of radiotherapy for head and neck cancer patients. Contralateral submandibular gland transfer (SMG-T) before radiotherapy was shown to reduce xerostomia compared to pilocarpine. We sought to evaluate a modification of this surgery preserving the ipsilateral facial artery and vein to simplify the SMG-T. Eighteen patients planned for head and neck intensity modulated radiotherapy to both necks were reviewed. Surgical complications were recorded. The grade of xerostomia was assessed after treatment completion. There were no minor or major complications resulting from the modified SMG-T. At 24.5-months follow up, the incidence of post-treatment moderate to severe xerostomia was 16.7%. No locoregional recurrence occurred. Only one patient had distant solitary lung metastasis. The modified SMG-T technique is a practical and effective method to reduce the dose of radiation to the contralateral SMG and limit post-treatment xerostomia.

Functional outcomes of the modified submandibular gland transfer procedure.

Treatment for advanced head and neck cancers typically includes surgery followed by radiation therapy (RT). Radiation-induced xerostomia is a common sequela of these treatments. The modified submandibular gland transfer (M-SGT) procedure was developed to decrease xerostomia in the treatment of oral cavity cancer by sparing one submandibular gland (SMG) from radiation. This study's objectives were to: 1) elucidate the radiation-sparing capacity of the M-SGT, and 2) study the xerostomia-reducing potential of the M-SGT based on the University of Washington Quality-of-Life Questionnaire (UW-QOL). Radiation therapy treatment plans were reviewed for all patients treated with surgery and RT who had a M-SGT at the University of Alberta Hospital during the study period. Outcomes included: 1) radiation dose received by the transferred SMG within the periparotid area compared to the submandibular triangle (ST), and 2) patient-reported saliva scores on the UW-QOL compared to historical controls without a gland transfer. Twenty-two patients were included. The mean radiation dose received by the transferred SMG was 29.00 grays (Gy) (standard deviation 14.59 Gy), thus reducing the mean radiation dose to the SMG by a statistically significant 18.34 Gy (confidence interval 95% (13.37, 23.32), P < 0.01) compared to the ST and below the D50 of the SMG (34 Gy). Sixty-five percent of patients rated their saliva as normal or mildly reduced on the UW-QOL as compared to 16% of controls (P = 0.01). The M-SGT technique is successful at reducing the radiation dose sustained by the SMG during adjuvant treatment and provides a significant improvement in xerostomia-related functional outcomes as compared to historical controls not receiving a gland transfer. 4 Laryngoscope, 130:925-929, 2020.

Implementation of submandibular gland transfer: A multi-institutional study of feasibility and time to treatment.

Submandibular gland transfer (SMGT) mitigates radiation-induced xerostomia but has yet to be widely adopted. We evaluate the feasibility of incorporating SMGT at multiple academic institutions and report the incidence of treatment delay. Forty-nine patients were identified who underwent SMGT. Time points pertaining to diagnosis and key treatment events including SMGT, surgery, chemotherapy, and radiation were extracted. Treatment delay was defined as either >60 days from diagnosis to definitive therapy or >6 weeks between surgery and adjuvant therapy. Median time from diagnosis to primary treatment was 42 days (IQR, 32-54). Median time from surgery to adjuvant therapy was 33 days (IQR, 28-47). Delay in starting treatment was observed in 7/49 patients (14%). Six patients incurred a delay in postoperative radiation therapy (6/19; 32%). With appropriate care coordination, SMGT can be implemented into a clinical pathway with a goal of decreasing radiation-induced xerostomia without increasing treatment delays.

Long-term outcomes of interventions for radiation-induced xerostomia: A review.

Xerostomia, or dry mouth, is a significant problem affecting quality of life in patients treated with radiation therapy for head and neck cancer. Strategies for reduction of xerostomia burden vary widely, with options including: sialagogue medications, saliva substitutes, acupuncture, vitamins, hyperbaric oxygen, submandibular gland transfer, and acupuncture or associated treatments. In this review, we sought to evaluate long-term outcomes of patients treated with various interventions for radiation-induced xerostomia. A literature search was performed using the terms “xerostomia” and “radiation” or “radiotherapy”; all prospective clinical trials were evaluated, and only studies that reported 1 year follow up were included. The search results yielded 2193 studies, 1977 of which were in English. Of those, 304 were clinical trials or clinical studies. After abstract review, 23 trials were included in the review evaluating the following treatment modalities: pilocarpine (three); cevimeline (one); amifostine (eleven); submandibular gland transfer (five); acupuncture like transcutaneous electrical nerve stimulation (ALTENS) (one); hyperbaric oxygen (one); and acupuncture (one). Pilocarpine, cevimeline, and amifostine have been shown in some studies to improve xerostomia outcomes, at the cost of toxicity. ALTENS has similar efficacy with fewer side effects. Submandibular gland transfer is effective but requires an elective surgery, and thus may not always be appropriate or practical. The use of intensity-modulated radiation therapy, in addition to dose de-escalation in select patients, may result in fewer patients with late xerostomia, reducing the need for additional interventions.

Submandibular Gland Transfer: A Potential Imaging Pitfall.

The Seikaly and Jha submandibular gland transfer surgery is performed to facilitate gland shielding during radiation therapy for head and neck tumors to circumvent radiation-induced xerostomia. It results in an asymmetric postsurgical appearance of the submandibular and submental spaces. Our purpose was to characterize the morphologic and enhancement characteristics of the transferred submandibular gland and identify potential pitfalls in postoperative radiologic interpretation. This retrospective study identified patients with head and neck cancer who had undergone the submandibular gland transfer procedure at our institution. Chart reviews were performed to identify relevant oncologic histories and therapies. CT and MR neck imaging was reviewed to characterize morphologic and enhancement characteristics of the pre- and postoperative submandibular glands, as well as interpretive accuracy. Eleven patients with oropharyngeal and nasopharyngeal squamous cell carcinomas who underwent submandibular gland transfer were identified. The transferred glands were significantly lengthened in the anteroposterior dimension compared with contralateral glands (P < .001) and displaced anteriorly and inferiorly within the submandibular and submental spaces. Enhancement patterns of the transferred submandibular glands varied, depending on the time of imaging relative to the operation and radiation therapy. Submandibular gland transfer was acknowledged in the postoperative report in 7/11 cases. Errors in interpretation were present in 2/11 reports. After the submandibular gland transfer procedure, the submandibular and submental spaces lose their symmetric appearances as the transferred submandibular glands become lengthened and located more anteriorly and inferiorly, with variable enhancement characteristics. Familiarity with the postsurgical appearance of the transferred submandibular glands is key to accurate imaging interpretation.

Role of current strategies for preventing xerostomia in oropharyngeal cancer patients: A literature review

Xerostomia occurring as sequelae of radiation therapy results in oral complications, i.e., acid erosion, dysphagia, dysgeusia, periodontal diseases, taste disturbance, and dental caries. The best strategy should be to prevent damage of any salivary acini during the course of radiotherapy; therefore, we planned to look for all the strategies for its prevention. We searched PubMed, Google Scholar, and Oral and Dentistry database thoroughly and included all the relevant articles published in the past 12 years (2005–2017). We found the following strategies for the prevention of xerostomia during radiation therapy: amifostine, pilocarpine, Vitamin C, and Vitamin E, acupuncture, bethanechol, botulism toxin, histamine, insulin growth factor, submandibular gland transfer, intensity-modulated radiation therapy, radiation stents, stem cell transplantation, intravenous injection of adipose stem cells, lasers, and lidocaine HCL. These preventive methods not only maintain the morphology and function of salivary glands but also reduces the need for saliva-enhancing therapies later.

Management of donor and recipient veins in the vascularised autogenous submandibular gland transfer

Management of donor and recipient veins in the vascularised autogenous submandibular gland transfer

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.

Long-term effect of submandibular salivary gland transfer on radiation-induced xerostomia in patients with nasopharyngeal carcinoma

Objective:To investigate the long-term effect of submandibular salivary gland transfer on xerostomia induced by radiation in patients with nasopharyngeal carcinoma(NPC).Methods:A total of 70 eligible patients with NPC were divided into the test group(36 cases)and the control group(34 cases).In the test group,the submandibular salivary glands were transferred to the submental space before conventional radiotherapy (XRT)and shielded during XRT.Submandibular gland function and salivary fluid before and after radiotherapy, questionnaire of xerostomia at 60 months after XRT,and 5-year survival rate were compared between the two groups.Results:At 5 years after XRT,the trapping and excretion function of submandibular glands were significantly better in the test group(P=0.000 and P=0.000,respectively).The mean weight of saliva after XRT was greater in the test group than in the control group(1.65gvs.0.73g,P=0.000).Incidence of moderate to severe degree of xerostomia was significantly lower in the test group than in the control group (12.9%vs.78.6%,P=0.000).No significant difference was found in 5 year survival rate between the two groups(86.1%vs.82.4%,P0.05).Conclusion:Submandibular gland transfer procedure is safe for NPC patients. It can prevent XRT induced xerostomia and improve the quality of life of NPC patients.

Submandibular Gland Transfer for the Prevention of Postradiation Xerostomia in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis

Background: Submandibular gland transfer has been widely used to prevent postradiation xerostomia in head-and-neck cancers. However, there are still some controversies. Methods: Six databases were searched, data extraction was performed and the risk of bias was assessed by 2 reviewers independently. The meta-analysis was performed using Review Manager, version 5.2. Results: A total of 7 trials (12 articles) and 369 participants were included. Conclusions: The present clinical evidence suggests that submandibular gland transfer might be highly effective to prevent postradiation xerostomia in head-and-neck cancers without serious adverse events. However, more randomized controlled trials are still needed to confirm this conclusion.

Salivary gland scintigraphy in patients suffering from severe keratoconjunctivitis sicca. Evaluation of the viability of submandibular glands before and after transfer into the temporal fossa.

Low tear production or elevated tear evaporation can lead to severe keratoconjunctivitis sicca. In patients with this disease, the transfer of an autologous submandibular gland into the temporal fossa is currently the most common surgical lacrimal gland substituting procedure. We compared the pre- and postoperative viability of transferred submandibular glands. Altogether 16 submandibular glands had been transferred in 12 patients. The graft's viability was evaluated before and 0.5-1, 1-6 and 8-12 months after transplantation by dynamic salivary gland scintigraphies after application of 40-50 MBq 99mTc-pertechnetate. Quantitative analysis was performed by calculation and comparison of the glandula submandibularis-to-background-ratio (SBR) and the transplant-to-background-ratio (TBR). The scintigraphic results were correlated with the clinical follow-up. All grafts remained viable during clinical follow-up. Salivary gland scintigraphy yielded 15 true positive results and 1 false-negative result. Comparison of presurgical SBR and postsurgical TBR showed good correlation with the clinical course. In 10 patients at least one transplant-reduction was necessary due to excessive epiphora occurring averagely 8 months after transplantation. Our results show that salivary gland scintigraphy very exactly reflects the morphological and biochemical postsurgical changes in a transferred submandibular gland. Thus, it is a reliable tool to exactly and objectively evaluate the viability of the grafts in the postsurgical course.

Management of donor and recipient veins in the vascularied autogeneous submandibular gland transfer

Objective To discuss the management and selection of donor and recipient veins in the transfer of vascularied autogeneous submandibular gland (SMG).Methods The SMGs of 48 patients with severe keratoconjunctivitis were transfered to the temporal region by microsurgery from June,2002 to June,2013.The secreted saliva was used as the substitute of tear.Donor and accepting-site vessels,vessels crisis and managements,survival of grafts were retrospectively analysed.Results Transplantation succeeded in 45 patients and failed in 3.For donor veins,39 were facial veins,12 were venae comitantes of facial artery,1 was vein near the duct.For revipient veins,41 were superficial temporary veins,6 were deep temporary veins and 5 were veins in the upper neck.For revipient artery,except superficial temporary artery,deep temporary artery was also a good selection.After surgery,2/5 venous crisis cases were rescued by reanastomosising veins.TC99m examination suggested that the 49 TSMGs were survived,and the ducts were unobstructed.Follow up lasted for 6 months to 10 years,the symptoms of photophobia and anemophobia were alleviated,the symptoms of corneal xerosis disappeared.Good clinical efficacy was obtained after transplantion.Conclusion During SMGs transplantion,facial veins,venae comitantes of facial artery or vein near the duct can be used for donor vein.For recipient veins,except the superficial temporary veins as major,deep temporary veins or veins in the upper neck is also a secection.Correct selection and microsurgical management of donor and revipient veins are keys to successful SMGs transplantion. Key words: Submandibular gland ; Transplantation ; Keratoconjunctivitis ; Vein

Clinical observation of submandibular gland transfer for the prevention of xerostomia after radiotherapy for nasopharyngeal carcinoma: a prospective randomized controlled study of 32 cases

BackgroundThe aim of this study was to evaluate the clinical efficacy of submandibular gland transfer for the prevention of xerostomia after radiotherapy for nasopharyngeal carcinoma.MethodsUsing the randomized controlled clinical research method, 65 patients with nasopharyngeal carcinoma were randomly divided into an experimental group consisting of 32 patients and a control group consisting of 33 patients. The submandibular glands were averted to the submental region in 32 patients with nasopharyngeal carcinoma before they received conventional radiotherapy; a lead block was used to shield the submental region during therapy. Prior to radiotherapy, the function of the submandibular glands was assessed using imaging. Submandibular gland function was measured using 99mTc radionuclide scanning at 60 months after radiotherapy. The data in the questionnaire regarding the degree of xerostomia were investigated and saliva secretion was measured at 3, 6, 12, and 60 months after radiotherapy. In addition, the 5-year survival rate was calculated.ResultsAfter follow-up for 3, 6, and 12 months, the incidence of moderate to severe xerostomia was significantly lower in the experimental group than in the control group. The average amount of saliva produced by the experimental and control groups was 1.60 g and 0.68 g, respectively (P < 0.001). After follow-up for 60 months, the uptake and secretion functions of the submandibular glands in the experimental group were found to be significantly higher than in the control group (P < 0.001 and P < 0.001, respectively). The incidence of moderate or severe xerostomia was significantly lower than in the control group (15.4% and 76.9%, respectively; P < 0.001). The 5-year survival rates of the experimental group and the control group were 81.3% and 78.8%, respectively, and there was no significant difference between the two groups (P = 0.806).ConclusionsAfter a 5 year follow-up period involving 32 patients who had their submandibular glands transferred for the prevention of xerostomia after radiotherapy for nasopharyngeal carcinoma, we found that clinical efficacy was good. This approach could improve the quality of life of nasopharyngeal carcinoma patients after radiotherapy and would not affect long-term treatment efficacy.

Submandibular Gland Transfer in the Treatment of Refractory Xerophthalmia

Objectives: Dry eye syndrome is a very common condition characterized by ocular irritation due to a deficient tear film. In mild cases, patients present with an annoying foreign-body sensation in the eyes. In its most severe form, it can cause ulceration of the cornea with spontaneous perforation and loss of the eye. There exists a small subpopulation of patients who suffer from extremely dry eyes. In these patients, routine surgical measures or medical management do not suffice to prevent complications. Submandibular gland transfer as a treatment for xerophthalmia has been studied and shown to be effective in other countries; however, the procedure is rarely used in the United States. Methods: We describe the procedure of microvascular submandibular gland transfer and discuss the outcomes in cases of submandibular gland transfer that have been performed at our institution to date. Results: In the series of patients reported from our institution, four procedures in three of the patients were successful, with improvement in epithelial defect on slit-lamp examination and/or improvement in tear production. Two procedures in the fourth patient were unsuccessful; the first was complicated by scarring of the submandibular duct, which was unsalvageable with revision surgery. The gland was removed and replaced with the opposite submandibular gland, but the transplanted gland proved non-viable. Conclusions: The technical expertise required for the transfer is readily available in almost all academic centers. The microvascular reconstructive surgeon has expertise in the harvesting of the flap, as well as in the transfer. When used, this technique provides an effective way to treat patients with refractory xerophthalmia.

Submandibular Gland Transfer in the Treatment of Severe Dry Eye Syndrome

Dry eye syndrome (DES) is a very common condition characterized by ocular irritation due to a deficient tear film. In its most severe form, it can cause ulceration of the cornea with spontaneous perforation and loss of the eye. There are many known causes of DES. They typically stem from conditions causing aqueous tear deficiency or increased evaporative losses. The most common cause being deficient tear production, this condition can be associated or unassociated with Sjogren Syndrome. Non-Sjogren related deficiencies include vitamin A deficiency, age related changes, and drug-induced. Sjogren-related DES is typically caused by connective tissue diseases. Lacrimal obstructive diseases are also included in this “aqueous tear deficiency” category and can be caused by post-radiation fibrosis, Stevens-Johnson Syndrome, or ocular pemphigoid. On the other hand, evaporative losses causing DES occur in the setting of facial paralysis or lid palsy, ectropion, and low blink rate.

Allogenic submandibular gland transplantation following hematopoietic stem cell transplantation

BackgroundAutologous submandibular gland transfer for treatment of progressive dry eye symptoms requires a functionally intact submandibular gland.In cases of total function loss of both lacrimal and submandibular glands this procedure has to be modified. Here we report on the first two cases of the allogenic transplantation of a submandibular gland to treat patients suffering from complete functional loss of both glands due to graft-versus-host disease (GvHD) following stem cell transplantation. MethodsWe carried out allogenic transplantation of the submandibular gland of the matched former stem cell donor to the temporal fossa of the stem cell recipient suffering from GvHD-induced dry eye. The treatment was carried out in two male patients who showed complete donor chimerism to the stem cell donors, so that no immunosuppressive therapy was applied. ResultsPostoperative clinical assessment of the patients revealed primary success of the procedure. The ocular surface showed improvement of lubrication and reduction of inflammatory signs. In the long-term follow-up sialoscintigraphy revealed lower tracer activity than expected and secretion of saliva-tears decreased. ConclusionEven though the so-called total donor chimerism was assessed allogenic transplantation of the submandibular gland following GvHD-induced dry eye showed signs of organ rejection and therefore initial immunosuppressive therapy after allogenic transplantation has to be considered.