lable at ScienceDirect

International Journal of Surgery 7 (2009) 503–509

Contents lists avai

International Journal of Surgery

journal homepage: www.thei js .com

Review

Surgical approaches to the submandibular gland: A review of literatureq

David D. Beahm a, Laura Peleaz a, Daniel W. Nuss a,b,c, Barry Schaitkin b, Jayc C. Sedlmayr c,Carlos Mario Rivera-Serrano b, Adam M. Zanation d, Rohan R. Walvekar a,*

a Department of Otolaryngology Head and Neck Surgery, LSU Health Science Center, 533 Bolivar Street, Suite 566 New Orleans, LA 70112, United Statesb Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA, United Statesc Department of Cell Biology and Anatomy, LSU Health Sciences Center, New Orleans, LA, United Statesd Department of Otolaryngology Head Neck Surgery, UNC School of Medicine, Chapel Hill, NC

a r t i c l e i n f o

Article history:Received 4 July 2009Received in revised form4 September 2009Accepted 12 September 2009Available online 24 September 2009

Keywords:Submandibular glandCadaveric dissectionSurgical approachesSalivary glands

q Grant support: None.* Corresponding author. Assistant Professor, Depart

Neck Surgery, LSU Health Sciences Center, 533 BoOrleans, LA 70112. Tel.: þ1 504 568 4785; fax: þ1 50

E-mail address: rwalve@lsuhsc.edu (R.R. Walvekar

1743-9191/$ – see front matter � 2009 Surgical Assodoi:10.1016/j.ijsu.2009.09.006

a b s t r a c t

Objectives: Surgical excision of the submandibular gland (SMG) is commonly indicated in patients withneoplasms, and non-neoplastic conditions such as chronic sialadenitis, sialolithiasis, ranula and drooling.Traditional SMG surgery involves a direct transcervical approach. In the recent past, alternative approaches toSMG excision have been described in effort to offer minimally invasive options or better cosmetic results. Thepurpose of this article is to describe the surgical approaches to the SMG and present relevant surgical anatomyvia cadaveric dissection and a systematic review of literature to compare and contrast each technique.Study design: Cadaveric dissection with fresh human cadaver heads followed by a review of the literature.Methods: Cadaver heads were dissected via both the transcervical and transoral approaches to thesubmandibular gland with the use of endoscopic assistance when indicated. Key landmarks andanatomic relationships were recorded via photo documentation. A review of the literature was con-ducted using a Medline search for approaches to SMG excision, including indications, results andcomplications.Results: While the traditional SMG excision remains a direct transcervical approach, many other methodsof excision are described that include open, endoscopic, and robot assisted resections. The approachesvary from being transcervical, submental, transoral or retroauricular.Conclusions: Alternative approaches to the SMG are feasible but should be tailored to the individualpatient based on factors such as pathology, patient preferences, availability of technology, and theexperience and skill of the surgeon.

� 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Surgical incisions to access to head neck lesions have rapidlyevolved from traditional incisions along natural skin creases oraesthetic units to more cosmetically acceptable incisions in the localregion or from remote locations that permit comprehensive surgery.These access incisions are often smaller and complemented byendoscopy, robotic instrumentation, and laparoscopic techniquesthat allow the surgeon to achieve and maintain an excellent oper-ative exposure and view. The impetus to move to more minimallyinvasive techniques has been that these procedures are associatedwith better cosmesis, less scarring, diminished blood loss, shorterhospital stay, and lower morbidity.

ment of Otolaryngology Headlivar Street, Suite 566, New4 568 4460.).

ciates Ltd. Published by Elsevier Lt

In the recent past, there have been several articles discussingnovel approaches to excise the submandibular gland (SMG). Surgicalexcision of the SMG is commonly indicated in patients withneoplasms, chronic sialadenitis, sialolithiasis, and to manage chronicdrooling (sialorrhea) not responsive to conservative treatment.While the classic SMG surgery has involved a transcervical approach,several other approaches have recently been described that can beclassified as ‘open’ or ‘endoscopic’ approaches (see Table 1).

The purpose of this article is to review the surgical approachesto the SMG in order to provide a comprehensive review of thevarious surgical approaches to the SMG. The various approacheswill be compared and contrasted in order to highlight the advan-tages and disadvantages of each technique.

2. Relevant anatomy

The submandibular triangle is delineated by the anterior andposterior bellies of the digastric muscle and the mandible. Anteriorly,the floor of the triangle is the mylohyoid muscle; posteriorly it is the

d. All rights reserved.

Table 1Classification of approaches to the submandibular gland.

Open Endoscopic

Transoral approach Endoscopy assisted

External approach Transoral

Lateral transcervical Submental

Retroauricular Lateral transcervical

Submental Completely endoscopic

Robot-assisted approach

Fig. 2. Arterial Supply to the Submandibular gland. (SMG: Submandibular gland; FA:Facial artery with branches to the submandibular gland; DG: Anterior belly of digastricmuscle).

D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509504

hyoglossus muscle.1 The SMG occupies most of this triangle, belowthe mylohyoid muscle.2 A part of the gland extends around the freeedge of the mylohyoid muscle that divides the gland into a smalleranterior and larger posterior part. The mylohyoid muscle must beretracted in order to gain access to the both parts of the gland.3 Thesubmandibular duct, or ’’Wharton’s duct’’, is approximately 5 cm inlength and arises from the anterior portion of the gland. It traversesthe floor of mouth between the mylohyoid and genioglossus musclesalongside the tongue. Its opening is found at the base of the frenulumof the tongue just posterior to the inferior incisors on the subman-dibular caruncle via one to three orifaces.1,2

The sublingual space is an important anatomical region that liesbetween the tongue and the mandibular ramus containing the deepportion of the sublingual gland, the anterior portion of the Wharton’sduct, and the lingual nerve which carries parasympathetic nervefibers to the gland. During its course, the lingual nerve loops underthe duct running a lateral to medial course and travels deep andsuperior to the SMG (Fig. 1); it is most easily identified by reflectingthe posterior portion of the mylohyoid muscle.2 Also relevant is thehypoglossal nerve, which lies inferior and medial to the lower thirdof the gland under the posterior belly of the digastric muscle.3

The SMG is enclosed within a sheath formed by the investingfascia of the neck that is attached superiorly to the mandible. Themarginal mandibular nerve forms an important external landmark asit passes just superficial to the fascia of the SMG and deep to the plane

Fig. 1. Lateral Transcervical approach. The lingual nerve loops under the duct runninga lateral to medial course and the travels deep and superior to the submandibulargland. The hypoglossal nerve lies inferior and medial to the lower third of the glandunder the posterior belly of the digastric muscle.

of the platysma.4 Consequently, surgical dissection within the fasciaof the SMG poses the least risk to the marginal mandibular nerve.

The vascular pole of the gland is formed by the facial arteryand vein(Fig. 2). Identification and ligation of these vessels permits completeliberation of the gland in any approach. The facial vessels traversevertically through the submandibular triangle across the mandible.2

3. Methods

A review of the literature was conducted using a Medline searchfor approaches, indications, results, and complications of SMGexcision. Relevant anatomy was further illustrated through cadav-eric dissection and photo documentation. A synopsis of the varioussurgical approaches to the SMG is provided. Fig. 3 (A, B, and C)illustrate the postauricular, lateral transcervical, and submentalsurgical incisions used to access the SMG in frontal, lateral, andsubmental views.

4. Results

Twenty seven articles were identified for review. Each article wasassigned a rating of the level of evidence as outlined by the USPreventive Task Force.5 Overall, 3 level II-2 studies were identified and22 level III studies were identified. There were no articles identifiedthat exhibited level I, II-1, or II-3 evidence. The articles were stratifiedaccording to operative technique categorized by us as either ‘‘open’’ or‘‘endoscopic.’’ The ‘‘endoscopic’’ category was further subdivided into‘‘endoscopy assisted’’ and ‘‘completely endoscopic’’ (Table 1). Theopen technique approaches include: the lateral transcervical, sub-mental, retroauricular, and transoral approaches. The endoscopicassisted approaches include the lateral transcervical, submental, andtransoral endoscopy assisted approaches. The completely endoscopicapproach includes the robot assisted techniques. Advantages anddisadvantages of each technique are summarized in Table 2.

5. Discussion

5.1. Open techniques

5.1.1. Lateral transcervical approachThe lateral transcervical approach is the standard and time-

tested means of surgical access to the SMG. Indications for excisionvia this approach include neoplasm of the SMG, chronic

Fig. 3. A–CCervical incisions (postauricular, lateral transcervical, and submental) for approaches to the submandibular gland (A:Frontal view; B:Lateral view; C:Submental view).

D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509 505

sialadenitis, sialolithiasis, radioactive iodine-induced sialdenitis,6

chronic drooling, Kuttner tumor and Kimura disease.7–9 Someauthors have advocated a partial or total submandibular resectionvia a transcervical approach for facial rejuvenation.10

Lateral transcervical submandibular resection is mostcommonly performed under general anesthesia. However, someauthors advocate SMG resection under local anesthesia in a selectpatient population. Criteria for gland excision under local anes-thesia include a clinically mobile mass without features of malig-nancy based on fine needle aspiration biopsy (FNAB) in patientswho prefer local anesthesia or are at high risk with general

Table 2Advantages and Disadvantages of Reviewed Surgical Approaches to the SMG.

anesthesia. In addition, there was no size limitation to the removalof the mass provided it was deemed to be resectable with a 6 cmincision. In their study, Chow et al. had no procedures that requiredconversion to general anesthesia. They conclude that SMG excisionunder local anesthesia is feasible in appropriately selected patientsand ultimately can shorten hospital stay and facilitate daysurgery.11

The standard lateral transcervical approach is described inTable 37,8 for comparison with other newer approaches that will besubsequently discussed. Complications of traditional SMG exci-sion include hematoma (2–10%), wound infection (2–9%), fistula

Table 3Traditional approach to the submandibular gland: lateral transcervical approach.

� A 4–6 centimeter incision in placed in lateral neck crease approximately 2 to 3centimeters below the lower edge of the mandible.

� Subplatysmal skin flap is developed and the marginal mandibular nerve isidentified and protected.

� The facial vein is identified and ligated at the inferior border of the gland andreflected superiorly with the fascia over the submandibular gland. Thismaneuver exposes the submandibular gland and ensures protection of themarginal mandibular nerve.

� The facial artery is ligated or may be preserved by ligating only the branchesof the facial artery to the gland.

� Blunt dissection then continues towards the superiomedial gland at whichpoint the mylohyoid muscle must be retracted anteriorly to complete thedissection.

� Posterior and inferior traction on the gland facilitates identification anddifferentiating Wharton’s duct, the lingual nerve with its attachment to thesubmandibular ganglion, and the hypoglossal nerve.

� The submandibular duct is then ligated and divided close to its opening in thefloor of the mouth.

� The gland is liberated from the submandibular ganglion and removedpreserving the lingual and hypoglossal nerves.

Fig. 4. Submental approach.

Fig. 5. Retroauricular approach. View of skin flap elevated prior to full exposure of thesubmandibular triangle.

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formation (1–3%), and neurological complications. Neurologicalcomplications include damage to marginal mandibular (7.7–36%),hypoglossal (0–7%) and lingual (0–22.5%) nerves.6–9,12,13

5.1.2. Submental approachThe submental approach provides access to the submandibular

triangle via a midline horizontal incision just superior to the sub-mental-cervical crease at the level of the hyoid bone, (4.5�1.9 cm).The location is patient dependent determined by pre-existing neckcreases, amount of submental fat and skin texture. The site of theincision is marked pre-operatively along the least prominent line ofthe submental area in the frontal and lateral views of the face and theneck. The submental approach allows quick access to the gland. TheSMG is bluntly dissected free of surrounding fascia in a subplatysmalplane. The dissection differs from the traditional approach in that theanterior free edge of the gland is first encountered (Fig. 4A and B).Following this, the facial vein and artery are ligated and the gland isseparated from the edge of the mylohyoid muscle. The submandib-ular ganglion is identified and separated from the gland. Finally thesubmandibular duct is ligated and the gland is delivered through theincision. A drain is placed within the incision and is removed on thesecond or third postoperative day.14

Roh compared the submental approach to the traditional lateraltranscervical approach in a prospective randomized fashion. Therewere a total of 20 patients, with 10 patients in each arm of the study.There were no statistically significant differences in the twoapproaches with respect to incision length, operative time, nerveinjuries, and number of days of hospitalization. However, theaverage visual analog scales measurements showed a higher patientsatisfaction due to cosmetic concerns in the submental approachgroup (p¼ 0.01; 8.8� 1.9 vs. 5.4� 3.2).14

5.1.3. Retroauricular approachRoh also described a retroauricular approach to the SMG.15 Since

the initial report in 2005, Roh and other authors have continued toreport on the utility of this approach.16 The main advantage is theimproved cosmesis of the resultant scar. The incision is designed inthe lower portion of the postauricular sulcus arching toward themiddle to upper 1/3rd of the sulcus before transitioning across anddownward into the hairline; the portion of the incision in thehairline is set ½ to 1 cm into the hair bearing area (Fig. 3B). Themain disadvantage of the retroauricular approach is the extent ofthe skin flap that must be raised to access the Wharton’s ductproximally which can be 10 cm from the postauricular incision. The

incision is carried downward through the subcutaneous tissues andonto the sternocleidomastoid muscle at which point the flap iselevated anterior to the SMG. Special attention must be paid toavoid damage to the hair follicles and great auricular nerve and itsbranches during flap elevation in order to prevent postoperativecomplications. Once the gland is exposed, extirpation proceeds asin any open approach.15 Due to the depth of the operative field(Fig. 3), endoscopy can enhance the view of the operative field(Fig. 5).

In his study, comparing this approach to the standard trans-cervical approach, Roh found no significant differences in operativetime, scar hypertrophy and length of hospital stay between the twoprocedures. In his series, there were no iatrogenic palsies of themarginal mandibular nerve with the retroauricular approach, while

D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509 507

there were two such reported complications with the standardapproach. The study concluded that the retroauricular approach issafe and comparable to the standard approach. As would beexpected, the overall patient satisfaction with the resultant scar ona visual analog scale was significantly higher with patients from theretroauricular cohort (p< 0.001; 8.9þ/� 0.9 points vs. 4.2þ/� 2.9points).16

5.1.4. Transoral approachWhile first described in modern medical literature in 1960,17 the

transoral approach to the SMG had not gained popularity untilrecently described by Hong et al18,19 (see Table 4). Advantages of thetransoral approach include: less risk of iatrogenic injury to themarginal mandibular nerve, avoidance of an external scar, minimalrisk of postoperative mucocele formation, or inflammation ofWharton’s duct.18,19 In his series, Hong reported on 31 patients whounderwent a transoral resection of the SMG and later followed thiswith a retrospective chart review of 77 patients undergoing thesame surgery showing similar results. Abnormal tongue sensationwas noted in 74% of patients and temporary limitation of tonguemovement was noted in 70% of patients.20 Restriction of tonguemovement due to scar contraction was noted in 10% of patients inthe first paper but this was lowered to 2% in the most recent articlewith these patients being asymptomatic.18,20 Hong later followedthe initial report with a review of 12 patients with pleomorphicadenoma of the SMG excised with this approach. They noted 50%of patients had anesthesia of the tongue and 40% had limitation oftongue movement, all of which resolved within two weeks ofsurgery.21 Weber et al. have published their experience with sevenpatients reporting 43% abnormal tongue sensation, no change intongue movement or restriction due to scar contracture. Theyattributed their lower complication rates to several criticalmaneuvers such as planning to leave a cuff of gingival mucosa toallow a tension free closure and prevent tongue tethering. Theauthors limited the amount of lingual nerve dissection conse-quently limiting stretch injury to the nerve which is responsible forabnormal tongue sensation. The authors pointed out that the onlypatient in their experience where a transoral approach was inad-equate to allow excision of the gland had previous surgery anda small oral cavity. These can be considered as relative contrain-dications to this approach.19 Kauffman recently reported a caseseries of nine patients with only 25% of patients having temporarychange in tongue sensation and no patients having lastingcomplications. This series further validates the safety of transoralexcision in selected patients.22

5.2. Endoscopic approaches

As technology advances and the boundaries of the endoscopeare ever challenged, it logically follows that this technology be

Table 4Transoralapproach to the submandibular gland.

� An incision is made in the floor of mouth from the submandibular papilla tothe retromolar trigone.

� A cuff of mucosa on the gingival side is preserved to allow for tension freeclosure and to prevent limitation of tongue mobility due to scar contracture.

� The lingual nerve is identified and dissected free of its attachments to thesubmandibular duct and gland.

� The submandibular gland is bluntly dissected and delivered into the surgicalwound by applying external pressure on the neck.

� The hypoglossal nerve is identified and preserved.� Branches of the facial artery and vein are ligated with care not to disrupt the

marginal mandibular branch of the facial nerve.� The gland is removed and the wound bed irrigated and closed in a tension

free manor.

applied to the excision of the SMG. Endoscopic approaches to theSMG can be further classified as ’’endoscopy assisted’’ and‘‘completely endoscopic’’ approaches.

5.2.1. Endoscopic-assisted transoral approachEndoscopically-assisted transoral excision of the SMG again is

similar to its open counterpart. The main advantage of the endo-scopic assistance in addition to those that are natural to thetransoral approach i.e. lack of a cervical scar and lower incidence offacial nerve palsy again, are good visualization, magnification andillumination of the anatomical landmarks, and consequentlya wider surgical field as compared to the conventional intraoralapproach (Figs 6 and 7). Guerrissi and Taborda describe two caseswith this technique which were successfully performed for siala-denitis secondary to sialolithiasis.3 However, Weber et al did notperceive any difficulties with exposure via the conventionaltransoral incision. In their series, a single patient required conver-sion to a transcervical approach which in their opinion would nothave been preventable even with endoscopic guidance.19

It must be recognized that the endoscopy assisted transoralapproach has several disadvantages which are common to all endo-scopic procedures and include: the cost of the endoscopic equipment,the learning curve associated with the surgeon becoming familiarwith the technique, and increased operative and setup time.23

5.2.2. Endoscopic-assisted submental approachChen et al., describe a minimally invasive endoscopic invasive

resection of the SMG. The incision placement for this approach is ina submental area similar to the submental approach described byRoh et al.24 This procedure differs from the conventional submentalapproach in that a smaller incision (20–25 mm) is placed over theskin crease in the hyoid midline. Dissection is performed in a sub-platysmal plane. The first assistant maintains an operative viewusing an endoscope and the second assistant maintains the workingspace with two retractors which lift up away from the skin. Vesselsare ligated using Endoclips (Ethicon Endosurgery) and excision isperformed standard fashion using an ultrasound-activated scalpel(Harmonic Scalpel, Ethicon Endosurgery). A drain is placed fordrainage.25

Fig. 6. Transoral approach. Endoscopic view of transoral approach showing subman-dibular duct (D), lingual nerve (L), and sublingual gland (SLG).

Fig. 7. Transoral approach. Endoscopic view of the operative field.

D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509508

The advantages of this approach include a smaller incision ascompared to the standard submental approach and the previouslydiscussed advantage of endoscopic visualization. In addition, theuse of an ultrasound-activated scalpel which does not transmit anelectric current reduces the risk of thermal injury to the marginalmandibular nerve as compared to monopolar and bipolar electro-cautery.26 However, the disadvantages include those that arecommon to all endoscopic procedures as well as a significantincrease in operative time as compared to the conventional sub-mental approach [70 min, (50–120 min) vs. 41 min, (32–56 min)].25

The application of endoscopic approaches in soft tissue surgeryhas been thwarted by the challenges fundamental to endoscopicneck surgery including the lack of a well-defined sac and the risk ofemphysematous dissection.23 The risk of CO2 insufflation to createa working space in the neck includes massive subcutaneousemphysema, hypercarbia, gas embolization, and some types ofarrhythmias.25 Terris et al, developed hybridized techniques toenable an endoscopic approach for the resection of the SMG ina porcine model.27 However, the era for endoscopic neck surgerybegan with the first description of a parathyroidectomy using CO2

insufflation.28,29 Since then there have been number of reports thathave used CO2 insufflation for the purpose of endoscopic necksurgery. These developments will certainly define the approaches tothe SMG in the future.

5.2.3. Endoscopic transcervical approachGuyot et al (2005) described an endoscopic approach for the

SMG that does not rely on CO2 insufflation to create an operativepocket. In a cadaveric study carried out on 6 non-embalmedcadavers, 12 endoscopic submandibular resections were per-formed. Access to the subplatysmal plane of dissection was ach-ieved via two 15 mm incisions (one anterior and the otherposterior), 10 mm below the submandibular area. A 4 mm diam-eter, 30-degree endoscope provided the surgical view when placedin the posterior incision. The operative pocket was created andmaintained using trans-cutaneous sutures. The dissection wasotherwise conducted in a usual fashion. Extirpation of the glandwas done through one of the incisions. In all cases gland excisionwas successful. The operative time decreased with experience from120 min for the first case to 35 min for the last case. The limitationsfor an endoscopic approach were defined as presence of

inflammatory adherences to surrounding structures that resultedin a bloody surgical field.30

5.2.4. Endoscopic submandibular gland excision using CO2

insufflationMonfared et al (2002) described an endoscopic approach to the

SMG in a porcine model using balloon dissection to create an oper-ative pocket which was constantly maintained with low pressure (nomore than 4 mm Hg) CO2 insufflation. Three incisions were made.The central 14 mm incision accepts the 12 mm trocar which housesthe endoscope while the two lateral incisions (6–7 mm) were used toplace the 5 mm operative trocars. Twelve SMGs were successfullyexcised endoscopically in seven pigs with no conversion to opensurgery. The median operative time was 59 min (range, 42–165 min).27 Terris recently expanded this approach with the additionof the daVinci robotic system to resect the SMG with a mean oper-ative time of 48 min and with no conversions to open surgery.27,31

The main advantage of the robotic-enhanced endoscopic surgeryincludes a virtual three dimensional vision projection system with anendoscopic arm and two operative arms that can be controlled by thesurgeon from a remote console. In addition, the robotic arm permitsuse of a full range of articulated instruments which can reproducesurgical maneuvers in difficult to access locations. The disadvantagesof robotic surgery such as high cost and lengthy setup time are great,and further customization of surgical instrumentation for otolaryn-gology practice remain to be challenges for the future.23,32

6. Conclusions

Newer approaches to the SMG have distinct advantages in termsof cosmesis over the traditional lateral transcervical approach.Although most approaches are feasible and have been successfullyperformed in humans, they are not widely practiced or accepted asstandard of care in most academic institutions and also incommunity settings. In cases where SMG resection is deemednecessary, we recommend careful selection of the approach basedon individual patient characteristics and needs, skill and experienceof the surgeon, familiarity with endoscopic technique, and avail-ability of necessary instrumentation.

Conflicts of interestNone

FundingNone

Ethical approvalNot applicable

Acknowledgement

The authors would like to thank Dr. Richard Whitworth and Dr.William Swartz, Mr. Antony Wells and Mr. Reginauld Delmore,Department of Anatomy; Jeffrey LaCour MD, Department ofOtolaryngology Head and Neck Surgery, Louisiana State UniversitySchool Health Sciences Center, New Orleans, LA; Eugene New, NewOrleans, LA (for illustrations), and Trey Joseph, Stryker, NewOrleans, LA for their contributions.

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