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J. B. Gottlieb and L. Cascarini
a
Still, when dealing with SMG calculi, there are some limitations on nonsurgical or minimally invasive techniques.
Whereas most of the stones located in the distal two-thirds of
the Wharton’s duct are amenable to endoscopic treatment
and may require a small incision to facilitate removal of the
53% Hilum
stone (Fig. 18.2), the hiloparenchymal impacted stones
found distal to the safe zone (Fig.18.3), and those in close
proximity to the lingual nerve, require more extensive dissection in order to facilitate stone removal. A thorough
knowledge of the anatomy of the region is required to avoid
possible complications.
10% Intraparenchymal
duct system
b
Anterior
third
Fig. 18.1 (a) Distribution of stones within the submandibular gland
(SMG) ductal system. (b) The three parts of the submandibular duct, as
well as the course of the lingual nerve (blue) from lateral to medial and
under the SMG duct
Middle
third
Posterior
third
c
Fig. 18.2 A 62-year-old diabetic, hypertensive, dialysis-dependent
patient suffered recurrent swelling episodes for more than 15 years
before seeking help for the problem. (a) Stone (black arrow) located in
the middle third of the left SMG duct on orthopantomogram view. (b)
Intra-oral view after performing sialolithotomy by incision directly on
the stone surface and suturing. (c) Stone extracted in two parts, measuring 2.3cm
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183
a
c
d
b
Fig. 18.3 A 58-year-old diabetic patient presented with an acute swelling of the right SMG due to a deep hiloparenchymal impacted stone,
which was retrieved by transoral removal of the intraductal stone. (a)
Axial CT view shows the stone impacted in a relatively posterior location in the right SMG ductal system. Note the peripheral edema and
18.2 Preoperative Checklist
The preoperative workup for a transoral SMG sialolithotomy
case should include one or more imaging studies and other
methods to conrm the diagnosis and determine the precise
location of the stone and any additional stones in the ductal
system.
18.2.1 Imaging Studies andPalpation
• High-frequency ultrasound (US) examination is the
method of choice to conrm the diagnosis [13] The use of
ascorbic acid improves US visualization of the salivary
gland duct in cases of obstruction [14].
• Conventional radiography includes occlusal and lateral
occlusal lms, orthopantomogram view (see Fig.18.2).
• Other tools available for the detection of stones [15, 16]:
– Direct visualization/imaging by sialendoscopy
mild airway deviation. (b) Coronal CT view. Note the inferior position
of the stone relative to the inferior border of the mandible. (c) 3D reconstruction CT lateral view of the stone inferior to the mandible inferior
border. (d) The extracted stone after transoral removal performed under
general anesthesia
– Sialogram study
– Cone beam computed tomography (CBCT)
– Magnetic resonance sialography
• A careful bimanual palpation should be done in the initial
assessment:
– Detection of the stone in the oor of the mouth
– Assessment of bone mobility
– Evaluation of the ease of the procedure, regarding the
stone’s size and location
• The bimanual palpation should be repeated immediately
preoperatively to conrm that the stone has not moved.
18.2.2 Other Considerations
The most important considerations, other than the stone size,
are the stone’s anteroposterior location and its location in the
vertical plane relative to the oor of the mouth.
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J. B. Gottlieb and L. Cascarini
Always be aware of additional stones within the SMG
ductal system. The formation of multiple stones is more prevalent in the SMG than in the parotid gland. In total, multiple
stones have been discovered in 16.9% of patients [4, 17].
18.2.3 Anaesthesia
Transoral removal of hiloparenchymal stones can be performed under general or local anaesthesia. In the rst few
cases, it is advisable to perform the surgery under general
anaesthesia. General anaesthesia with nasal intubation is also
indicated when the stone is situated very deep and behind the
hilum (conrmed by an imaging modality to be located near
or below the inferior border of the mandible, also inferior to
the mylohyoid muscle), because of the amount of dissection
and retraction require to facilitate retrieval of these stones.
After the surgeon has gained some experience and profound understanding of the three-dimensional (3D) anatomy
at the hilar region of the SMG, easily palpable xed stones
situated at the entrance of the hilar region may be retrieved
under local anaesthesia.
Case selection should be extremely strict when planning
transoral removal of an intraductal stone to be performed
under local anaesthesia, however. Factors such as mouth
opening, stone location, and the amount of required dissection should be considered, as well as the presence of an
inamed duct or periductal tissues.
18.3 Indications
The indications for transoral removal of intracanalicular
SMG calculi are straightforward. The most important factor
to consider is whether the stone is palpable, and the second
most important issue is whether it is mobile or impacted.
These considerations apply to both a combined approach—
in which the sialendoscope is used to assist the surgeon in
delineating the stone location and exploring the intraparenchymal ductal system for additional stones after stone
removal—or a solely surgical approach. In addition to stone
removal, the other main goal should be preservation of the
lingual nerve, ductal system patency, and gland function.
When dealing with nonpalpable mobile stones, intraoperative localization may be very difcult, even when using
the sialendoscope from a hilar opening, owing to the profound branching nature of the intraparenchymal ductal
system.
It is agreed in the literature that most stones 4 mm in
diameter or smaller can be effectively managed by sialendoscopic techniques, but that stones larger than 5 mm will
require adjuvant conservative procedures such as extracorporeal shock wave lithotripsy or intracorporeal shock wave/
laser lithotripsy before their retrieval, or they should be managed by surgery alone.
Absolute indications for surgical removal include failure
of conservative nonsurgical techniques and sialendoscopy;
an impacted, nonmobile, palpable stone; or stone diameter
5mm or larger, with no possibility for fragmentation owing
to lack of equipment.
Relative indications include nonpalpable mobile or nonmobile stones, or a desire of the patient to go through one
surgery rather than a series of attempts at fragmenting the
stone.
Contraindications include complete atrophy of the gland
due to long-standing obstruction, very deeply situated intraparenchymal stones, or multiple intraparenchymal impacted
stones (Fig.18.4).
Figure 18.5 presents a decision ow chart to assist beginners in the eld of salivary gland sialolithiasis in choosing the
Fig. 18.4 A 36-year-old woman suffering from multiple intraparenchymal stones in the right and left SMG, which were not amenable to
transoral removal. She had no predisposing factors such as hyperpara-
thyroidism, which was ruled out. (a) Axial CT view. (b) Coronal CT
view. The right SMG gland was excised; the left SMG gland is being
followed up without any symptoms
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SMG stones
185
Anterior third
distal stone
S.E
Fig. 18.5 Flow chart to assist in achieving a treatment plan for SMG
stones in each third of the ductal system. There is usually more than one
treatment option in each situation, and the chosen technique is guided
by the equipment available and the technique most familiar and successful for the surgeon performing the procedure. Other factors inu-
T. O.S.R
L.A
≤4mm5-8mm >9mm
S.E
T. O.S.R
L.A
third stone
T. O.S.R
L.A/G.A
Middle
best management of SMG stones, based primarily on the
location of the stone within the ductal system (anterior, middle, and posterior thirds, as shown in Fig.18.1b), as well as on
other factors including the size of the stone and whether it Is
palpable. Further suggested readings to aid in decision making for beginners in the eld are the classication by Marchal
etal. [18] and the decision tree suggested by Foletti etal. [19].
18.4 Surgical Technique
Transoral submandibular approaches have risks that include
lingual nerve trauma and bleeding [20–23]. The surgical
technique described here follows McGurk’s intraoral stone
release technique [22] and shares some similarities with the
approaches of Zenk etal. [23] and Nahlieli etal. [21], with
the main difference being the conservation of the natural
papilla, which in our opinion follows the purpose of organpreserving, minimally invasive surgery to a greater extent.
1. Using a mechanical mouth opening prop (such as the
Ferguson mouth prop) on the contralateral side is
advised, to enable easy tongue retraction away from the
affected side. Do not use dental bite blocks, which will
limit the ability to retract the tongue away from the surgical eld. Tongue retraction is best achieved by the
index nger of the surgeon’s nondominant hand
(Fig.18.6). Using a medium-size gauze pad will prevent
the tongue from slipping from the retracted position.
2. Inltrating local anaesthesia (2mL Lignocaine with 1%
adrenaline) in the supercial submucosal layer, along
the planned incision line, will assist both in decreasing
the bleeding in the area and in developing the surgical
plane by means of hydraulic dissection.
3. A retropapillar incision is made about 5mm behind the
natural ostium of the Wharton’s duct (Figs.18.7, 18.8,
Posterior third
Hilo-parenchymal stone
Palpable Non-palpable
S.B
L.F
E.S.W.L
encing the treatment plan are the stone size and (in the case of
hiloparenchymal stones) whether it is palpable. ESWL Extracorporeal
shock wave lithotripsy, GA General anesthesia, LA Local anesthesia, LF
Laser fragmentation, SB Stone breaker (intracorporeal lithotripsy), SE
Sialendoscopy, TOSR Transoral stone release
T. O.S.R
L.A/G.A
T. O.S.R
L.A/G.A
S.B
L.F
E.S.W.L
T. O.S.R
L.A/G.A
Gland
excision
and 18.9), thus leaving the papilla in its natural position
and avoiding the reported narrowing scarring and stenosis that may follow when the incision is made at the
papilla itself. The incision line is made medial to the
sublingual gland, which usually can be seen as a yellowish semilunar structure in the submucosal space in the
anterior lateral aspect of the mouth oor; the line is
extended posteriorly and laterally up to the rst or second molar tooth on that side.
The initial incision should be done carefully and
supercially, with only the mucosa incised. A deeper
incision line may damage the underlying structures,
including vessels, lingual nerve, Wharton’s duct, sublingual gland, and intrinsic or extrinsic tongue muscle
(Fig.18.8). Incising into the tongue muscle puts you in
the wrong dissection plane and causes bleeding that
interferes with visualization.
Bleeding control is best achieved by means of bipolar
diathermy, which lowers the risk of thermal injury to the
lingual nerve and surrounding structures.
4. Identication of the duct in the retropapillar region is
quite straightforward, and dissection in the developed
plane should follow the duct path up to the hilar region.
Knowledge of the anatomy in the oor of the mouth is
crucial; keep in mind that the duct will be found under
the medial surface of the sublingual gland. Placing a
retraction suture within the sublingual gland and
retracting it anterolaterally will bring the duct to the
surface and simplify the dissection along the duct
(Fig.18.9).
5. When reaching the danger zone, behind the rst molar
tooth, the lingual nerve comes to lie superior to the canal
as it crosses from the lateral aspect to the medial aspect
of the duct. In our experience, this location is usually
where the hilar stones are found. Previous obstructive
episodes, together with the inammatory process, may
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J. B. Gottlieb and L. Cascarini
a
b
WP
SLG
WP
Fig. 18.7 The retropapillar incision line (dashed black line) should
start about 5mm distal to Wharton’s papilla (WP, black arrow), supercially in the mucosa to avoid the possible severance of the duct or
lingual nerve and blood vessels in the region. The incision line should
be just medial to the sublingual gland (SLG, ne black line). Performing
the incision in the parenchyma of the SLG poses a risk of postoperative
ranula formation
SLG
Fig. 18.6 (a) The tongue is retracted away from the left side by digital
retraction performed by the surgeon nger. A Ferguson mouth prop on
the right teeth facilitates room for the tongue. (b) Close-up view shows
the sublingual gland (SLG) outline (dashed black line) and yellowish
color seen through the mucosal layer, as well as Wharton’s papilla (WP,
black arrow)
cause some scarring and adhesions between the nerve
and the duct.
Very careful dissection should be done in the region.
Application by the assistant of manual digital pressure
Fig. 18.8 Following the retropapillar mucosal incision and development of the submucosal loose areolar tissue plane. Note the lingual
nerve (LN, black arrowhead) lying on the tongue intrinsic muscles, the
sublingual gland (SLG), and the Wharton’s duct (WD, blue arrow) as it
goes to the undersurface of the SLG.WP (black arrow)—Wharton’s
papilla
WPWPWPWPWPWPWPWW
S
S
DDDDD
D
ab
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187
LN
WP
SLG
c
SMG
LN
WD
WP
SMG
WD
SLG
LN
WP
Fig. 18.9 Developing the surgical plane. (a) Digital retraction of the
tongue away from the affected site reveals the oor of the mouth and
helps in delineating the anatomical landmarks. (b) Following incision
in a retropapillar position, 5mm behind Wharton’s papilla (WP) and
medial to the sublingual gland (SLG), the lingual nerve (LN) becomes
apparent after only a small amount of blunt dissection. The Wharton’s
on the gland extraorally in an anterior direction will
bring the hilar region and the stone to a more favourable
anterior location. (Fig.18.10). In this location, the separation of the nerve from the duct, as well as extraction of
the stone, is safer and easier. Applying this extraoral
pressure on the gland may be quite demanding, but it is
one of the crucial points of the technique. Before com-
WD
SLG
duct (WD) lies on the undersurface of the SLG as it runs posteriorly to
the submandibular gland (SMG). (c) Applying retraction of the sublingual gland (SLG) by a suture or forceps in an anterolateral direction
reveals the Wharton’s duct (WD) on the gland’s undersurface, here
shown after separation of the duct from the SLG
mencing with the ductal incision and stone removal,
allow the assistant some rest, as any movement or
decreased force in bringing the hilum forward may lead
to losing the surgical plane or stone.
At this point, the surgeon must decide whether to
make the ductal incision medial or lateral to the nerve
position in relation to the duct. When making the ductal
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J. B. Gottlieb and L. Cascarini
6. Performing the ductal incision on the stone is the next
a
step (Fig.18.11). Adhesions between the stone and duct
walls may occur as a result of the inammatory process.
Before making the ductal incision, a 20-mL irrigation
syringe with saline and a exible tip, a dental excavator
(to assist in the stone extraction from the duct), and a 6-0
absorbable Vicryl suture should be ready, as bleeding is
expected from the inamed duct wall.
WD
LN
SMG
S
WP
SLG
S
SMG
SLG
b
SMG
LN
S
b
WD
WP
SLG
S
Fig. 18.10 Intraoral stone release. (a) After dissection and separation
of the duct from surrounding anatomical structures, the assistant applies
extraoral pressure on the operated submandibular gland (SMG), which
brings the gland and stone (S) to a more favourable anterior position
that will allow the stone release procedure to be done under direct visualization, thereby decreasing the risk of injury to the lingual nerve (LN).
(b) The incision is made directly on the stone surface; at this stage, the
surgeon decides whether to make the incision in medial or lateral to the
nerve. Extension of the incision further anterior to the stone margin will
allow room to manipulate the stone out of the canal, a process that can
be demanding because the stone tends to be adherent to the canal walls
as a result of recurring episodes of inammation
incision, extend it further forward than the stone’s anterior edge, to allow easy stone manipulation and extraction from the duct.
SMG
SLG
Fig. 18.11 A sialendoscope-assisted transoral intraductal stone release.
(a) Note the sialendoscope in the right Wharton’s canal via the papilla of
the right SMG (black arrow). The gland and the stone (S) have been
brought into an anterior position by extraoral pressure applied by the
assistant. (b) Immediately after the incision is performed on the stone
surface, the stone is expelled, leaving a saccular cavity behind it
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other NSAIDs. If extensive postoperative swelling is anticipated, oral steroids (dexamethasone) may be given for a few
days.
Most patients have some level of oedema in the oor of the
mouth and in the submandibular region, due to swelling of the
operated gland. Usually, those symptoms subside in a few days
and are managed by a cold, soft diet, avoiding the use of sialagogues in the immediate postoperative period, and drinking at
least 2L of water a day. A few patients will suffer quite extensive swelling in the oor of the mouth that might necessitate
hospital admission for observation and management [20].
18.5.1 Long-term Outcome andAnatomical
189
Recovery oftheDuct After Transoral
Removal ofaHilar Stone
Fig. 18.12 Suturing the incision in the oor of the mouth with an
absorbable 4-0 Vicryl suture. Note once again the space provided for
tongue retraction to the left by the Ferguson mouth prop
7. Perform sialolithotomy. Following stone removal by aid
of a dental excavator or other instrument, irrigation is
done intraductally. In our experience, the irrigation itself
dislodges additional deeply located mobile stones if any
are present. Make sure that those stones, which are usually smaller, are not spilled and left in the oor of the
mouth, as they can cause postoperative infection. A thorough irrigation of the operative bed also should be done,
especially if inamed saliva or pus is expelled from the
canal after the stone removal.
8. Repair of the duct proximally can be technically challenging, and leaving it open is not likely to result in any
ill effect [19]. A 6-0 absorbable Vicryl suture is placed in
the edges of the incised duct when possible.
9. Suturing the oor of the mouth with an absorbable 4-0
Vicryl suture will complete the procedure (Fig.18.12).
10. Nahlieli et al. [21] reported injecting dexamethasone
12mg into the surgical eld and irrigating the gland with
hydrocortisone 100mg via the stent. Rinsing the surgical bed with tranexamic acid (1g) is also recommended.
These steps will reduce the postoperative oedema in the
oor of the mouth and SMG swelling, as well as the risk
of postoperative bleeding.
18.5 Postoperative Care
The postoperative recovery following transoral removal of
intracanalicular stones is quite individual. Patients are given
antibiotics such as amoxicillin/clavulanic acid for 5days following surgery, along with analgesics such as ibuprofen or
Several studies have been published regarding the long-term
outcome [10, 23, 24] and duct recovery, using sialograms
and long follow-up periods [25, 26]. All of these studies support and validate the use of organ-preserving surgery for
hiloparenchymal transoral stone removal, rather than performing sialadenectomy of the affected gland, as was
accepted in the past.
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treatment. Br Dent J. 1999;186:463–6.
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H.Nearly 3,000 salivary stones: some clinical and epidemiologic
aspects. Laryngoscope. 2015;125:1879–82.
11. Marchal F, Kurt AM, Dulguerov P, Becker M, Oedman M, Lehmann
W. Histopathology of submandibular glands removed for sialolithiasis. Ann Otol Rhinol Laryngol. 2001;110:464–9.
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12. Iro H, Zenk J, Escudier MP, Nahlieli O, Capaccio P, Katz P, et al.
Outcome of minimally invasive management of salivary calculi in
4,691 patients. Laryngoscope. 2009;119:263–8.
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14. Bozzato A, Hertel V, Bumm K, Iro H, Zenk J.Salivary simulation
with ascorbic acid enhances sonographic diagnosis of obstructive
sialadenitis. J Clin Ultrasound. 2009;37:329–32.
15. Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro
L. Modern management of obstructive salivary diseases. Acta
Otorhinolaryngol Ital. 2007;27:161–72.
16. Schwarz D, Kabbasch C, Scheer M, Mikolajczak S, Beutner
D, Luers JC. Comparative analysis of sialendoscopy, sonography, and CBCT in the detection of sialolithiasis. Laryngoscope.
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17. Nahlieli O, Iro H, McGurk M, Zenk J.Modern management preserving the salivary gland. Herzliya: Isradon Publishing; 2007.
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B, etal. Salivary stones and stenosis. A comprehensive classication. Rev Stomatol Chir Maxillofac. 2008;109:233–6.
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Submandibular Gland Excision
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OliverKaschke andMariusSchulz-Schönhagen
19
19.1 Introduction
19.1.1 Anatomy
The paired submandibular gland is the second largest salivary gland in the human body. It is historically known as the
submaxillary gland. It produces approximately 75% of
human saliva. The secretion consists of serous and mucoid
components. Each submandibular gland weighs about 15g.
The submandibular gland is located in the submandibular
triangle or Level Ib of the neck. The submandibular triangle
is bordered superiorly by the horizontal branch of the mandible, posteriorly by the anterior edge of the sternocleidomastoid muscle, and caudally by the posterior and the
anterior belly of the digastric muscle.
The submandibular gland is anatomically divided into a
supercial lobe and a deep lobe. The C-shaped mylohyoid
muscle divides these parts. The supercial lobe constitutes
the main mass of the gland; the deep lobe is smaller. The
mylohyoid muscle is one of the key structures when excising
the submandibular gland. It is a at muscle attached to the
mylohyoid line on the inner aspect of the mandible, the body
of the hyoid bone, and through a midline raphe to the
opposite- side mylohyoid muscle. It forms the so-called oor
of the mouth and separates the cervical part from the oral
part of the submandibular gland. The lingual nerve and the
hypoglossal nerve are both located underneath the mylohyoid muscle, whereas no substantial vascular or neurological
structures are running supercial to the mylohyoid muscle.
O. Kaschke (*)
Department of Head and Neck Surgery, Sankt GertraudenKrankenhaus, Berlin, Germany
e-mail: oliver.kaschke@sankt-gertrauden.de
M. Schulz-Schönhagen
ENT and Head and Neck Surgery, Sankt Gertrauden Krankenhaus,
Berlin, Germany
e-mail: marius.schulz-schoenhagen@sankt-gertrauden.de
The hyoglossus muscle is posteriorly located and separates the gland from the pharynx. Lateral to the hyoglossus
muscle runs the submandibular duct; the lingual artery is
medial. The digastric muscle is another important landmark
in submandibular gland surgery. It separates the prelaryngeal
space from the submandibular triangle at its caudal border.
The facial artery emerges directly medial to the posterior
belly. The hypoglossal nerve runs directly underneath to the
digastric tendon.
Three main nerve structures are adjacent to the submandibular gland:
• The marginal mandibular nerve, as part of the facial
nerve, consists of up to four parallel branches; it crosses
on top of the facial artery and facial vein before ascending
to innervate the depressor anguli oris muscle of the lower
lip. The marginal mandibular nerve runs within the layers
of the deep cervical fascia overlying the gland. The nerve
can loop up to 3cm below the horizontal branch of the
mandible. Injury of the marginal mandibular nerve causes
impaired lower lip movements on the damaged side,
resulting in asymmetric lip closure.
• The lingual nerve runs through the lateral oor of the
mouth just superior to the submandibular gland. It sends
secretomotoric nerve bres to the submandibular ganglion,
which then innervate the submandibular gland. The lingual
nerve is seen in the operating area during submandibular
gland excision, when the submandibular gland is retracted
inferiorly and the mylohyoid is retracted anteriorly.
• The hypoglossal nerve enters the submandibular triangle
medial to the hyoid bone and crosses the submandibular
triangle to exit into the mouth behind the mylohyoid mus-
cle. It traverses the medial wall of the submandibular tri-
angle, where it is attached to the hyoglossus muscle. The
hypoglossal nerve is covered by a thin layer of fascia, dis-
tinct from the submandibular gland capsule, and is accom-
panied by thin-walled veins that are easily torn in
surgery.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_19
191
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