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O. Kaschke and M. Schulz-Schönhagen
Vasoconstriction of the arteries that supply the submandibular gland’s secretions is regulated by the sympathetic
nervous system. Increased sympathetic activity reduces
glandular blood ow, thereby decreasing the volume of uid
in salivary secretions and producing an enzyme-rich mucous
saliva. Direct stimulation of sympathetic nerves will cause
an increase in salivary enzymatic secretions, however.
The vascular supply consists of three main arterial vessel
structures:
• The facial artery enters the submandibular triangle from
behind the posterior belly of the digastric and the hyoid
bone, runs across the surface of the submandibular gland,
and emerges at the superior aspect of the submandibular
gland, where it joins the facial vein to cross the mandible.
Some branches of the facial artery enter the submandibu-
lar gland. These branches must be divided if a buccinator
myomucosal ap is planned. In that case, the artery must
be preserved during resection of the submandibular gland.
• The submental artery is a branch of the facial artery and runs
along the inferior and medial margin of the mandible. The
submental artery is the base of the submental artery ap.
• The mylohyoid artery is a branch of the inferior alveolar
artery. It runs from the mandibular foramen to the mylo-
hyoid muscle and vanishes behind the digastric muscle.
The mylohoid artery and vein are found by elevating the
anterior margin of the submandibular gland. The mylohy-
oid artery is connected to both the submental artery and,
through the mylohyoid muscle, to the lingual artery in the
oor of the mouth.
The lymphatic drainage of the submandibular gland drains
rst into the submandibular lymph nodes and later into jugulodigastric lymph nodes. The secretion of the submandibular
glands is regulated directly by the parasympathetic nervous
system and indirectly by the sympathetic nervous system.
The secretion of saliva is promoted by parasympathetic activity. Parasympathetic innervation of the submandibular glands
is provided by the superior salivatory nucleus via the chorda
tympani. The chorda tympani consist of branches of the facial
nerve, which become part of the trigeminal nerve’s lingual
part and are synapsing at the submandibular ganglion.
The oral component of the submandibular gland extends
along the Wharton’s duct directly below the mucosa of the
oor of the mouth. The duct exits from the gland on the
medial surface between the mylohyoid and hyoglossus muscle and runs 5cm to the midline in the anterior oor of the
mouth, where it opens as the caruncula sublingualis.
19.1.2 Clinical Aspects
Submandibular gland surgery is performed by different surgical experts for a variety of indications. The most common
reason for submandibular gland excision is chronic sialadenitis with or without salivary stones. Sialolithiasis is the most
common salivary disease and the most common cause of
salivary gland dysfunction. The submandibular gland is the
site of 80% of salivary stones.
Transcervical extirpation of the gland is the gold standard treatment for submandibular gland disease. Although
submandibular gland excision is a relatively standardized
surgical procedure, complications are still frequently
reported. These complications include nerve paralysis or
paresis, aesthetic sequelae, hematoma, salivary stulas or
sialoceles (a subcutaneous cavity containing saliva), and
wound infections. Also frequently reported are keloid scars
and inammation caused by residual lithiasis in the salivary
duct.
19.2 Preoperative Checklist,
Considerations, andAnaesthesia
Preoperative examination should include evaluation and
bimanual palpation of the submandibular gland. An ultrasound examination is the gold standard in imaging of the
submandibular gland, by which size, texture, vascularization, and adherent or internal tumorous structures can be
identied. Ultrasound can be performed with or without neneedle aspiration biopsy prior to any other imaging. If there
is any suspicion of malignancy, a preoperative CT scan or
MRI should be performed. Sialography or sialoendoscopy is
another valuable diagnostic tool.
After providing surgical indications, the patient’s preoperative information should address key concerns, including
injury to the marginal mandibular nerve, the lingual nerve,
and the hypoglossal nerve, as well as the surgical scar.
Further risks are postoperative wound infection and postoperative bleeding caused by insufciently ligated and divided
vessels, leading to hematoma, laryngeal oedema, and possible surgical revision.
The surgeon should instruct the anaesthetist to avoid muscle relaxation, a precondition for precise intraoperative neuromonitoring of the marginal mandibular nerve. It is also
useful to watch for lower lip movement caused by stimulation or irritation of the marginal mandibular nerve during
surgery.
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19.3 Indications
Excision of the submandibular gland is often indicated for
treatment or prevention of a variety of inammatory and
neoplastic conditions, such as recurrent sialadenitis refractory to conservative treatment, sialodocholithiasis, sialorrhea, suspicion of malignant tumor, or Sjögren syndrome, or
as part of a level I neck dissection.
A contraindication could be poor medical condition in a
patient who cannot tolerate general anaesthesia. Massive
acute purulent sialadenitis should be treated with antibiotics
prior to surgery.
19.4 Surgical Technique withTips
The patient is placed in a supine position with the neck
extended and the head rotated to the contralateral side. The
skin of the anterior neck and lower face is sterilized. The
intraoperative neuromonitoring of the marginal mandibular
nerve is installed. Draping is done by exposing the lower lip,
the lower margin of the mandible, and the upper neck.
Prilocaine and epinephrine (1:100,000) is injected along
the planed incision line into the left upper neck. Horizontal
curvilinear incision is done along the relaxed skin tension
lines 3–4cm below the inferior border of the mandible or at
the level of the hyoid bone, to protect the marginal mandibular nerve (Fig. 19.1). The incision is extended anteriorly
from the anterior border of the sternocleidomastoid muscle
for 5–6cm. Horizontal dissection is done through subcutaneous tissue, the platysma muscle, and the supercial layer of
deep cervical fascia (Fig.19.2). The facial vein is identied
posterior to the submandibular gland. The facial vein is
ligated and divided near the inferior border of the gland and
is elevated to draw away the marginal mandibular nerve
superiorly from the gland. Blunt dissection frees the facial
vein and the fascia up to the inferior border of the mandible
(Fig.19.3).
The posterior inferior aspect of the submandibular gland
can immediately be identied anterior to the sternocleidomastoid muscle, where it overlays the posterior belly of the
digastric muscle. Once the superior margin of the submandibular gland has been reached, the fatty tissue is dissected
bluntly above the gland to identify the facial artery and vein
remaining directly above the submandibular gland, to avoid
injury to the marginal mandibular nerve (Fig. 19.4). The
facial artery is located inferiorly and transects posterolaterally near its origin from the external carotid artery, just above
the posterior belly of the digastric muscle.
Branches of the facial artery and facial vein entering the
gland are divided and ligated close to the gland. The cervical
branches of the marginal mandibular nerve to the platysma
muscle can be dissected proximally to nd the marginal
Fig. 19.1 Horizontal curvilinear incision is done along the relaxed
skin tension lines 3–4cm (two ngerwidths) below the inferior border
of the mandible from the anterior border of the sternocleidomastoid
muscle for 5–6cm
Fig. 19.2 Horizontal dissection is done through subcutaneous tissue, the platysma muscle, and the supercial layer of deep cervical fascia
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Fig. 19.3 The facial vein is ligated and divided near the inferior border of the gland and is elevated to draw away the marginal mandibular nerve
superiorly from the gland. The facial vein can be identied by blunt dissection of the fatty tissue at the cranial margin of the gland
O. Kaschke and M. Schulz-Schönhagen
Fig. 19.4 The facial artery and vein run posterolaterally from its transection at the posterior belly of the digastric muscle. Blunt hooks protect the
marginal mandibular nerve by retracting soft tissue at the mandible
mandibular nerve. Contraction of the depressors in the ipsilateral lower lip alerts the surgeon to proximity to the marginal mandibular nerve. Although not vital for the procedure,
the marginal mandibular nerve may be exposed at its crossing over the facial artery and vein through careful blunt dissection and identied by intraoperative neuromonitoring.
This manoeuvre is required if an additional level I neck dissection is to be performed for full removal of the contents of
level I, including the lymphatic nodes around the facial
artery. The use of monopolar cautery should be avoided in
the proximity of the nerve.
Subsequently, the anterior margin of the submandibular
gland is freed from the anterior belly of the digastric muscle
by retracting the gland inferiorly and posteriorly, employing
an Allis clamp or Babcock clamp for traction. Then the gland
is pulled laterally whilst its bottom is freed from the surface
of the mylohyoid muscle (Fig.19.5).
The digastric muscle is identied along its course,
including the common tendon and the anterior belly.
Below the digastric muscle (and therefore protected) runs
the hypoglossal nerve. Its course may be in close proximity to the inferior border of the gland. By retracting the
mylohyoid anteriorly and by using careful dissection, the
lingual nerve, submandibular ganglion, and Wharton’s
duct come into view. Gentle downward retraction of the
gland permits the view of the lingual nerve (Fig.19.6). Its
lowest point can be seen where it crosses the deep lobe of
the gland and the Wharton’s duct. One may now safely
clamp, divide, and ligate the submandibular duct and the
branches of the lingual nerve (Fig.19.7). Be careful not to
place the tie across the main nerve. Bipolar cautery, hemoclips, or suture ligature is placed on the submandibular
ganglion, permitting separation of the gland from the lingual nerve.
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Fig. 19.5 Using a clamp for traction, the gland is pulled laterally whilst its bottom is freed from the surface of the mylohyoid muscle
195
Fig. 19.6 The gentle downward retraction of the gland permits the view of the lingual nerve. Its lowest point can be seen where it crosses the deep
lobe of the gland and the Wharton’s duct
The duct of the gland is traced anteriorly and transected,
after placing of ligatures or hemoclips as distal as possible.
Retaining parts of the Wharton’s duct may predispose to
infection resulting from retained stone or debris in the
duct.
The submandibular gland can then be reected inferiorly,
and the facial artery is identied. If necessary, the artery is
ligated and divided where it exits from behind the posterior
belly of the digastric muscle. The submandibular gland is
then nally freed from the tendon and the posterior belly of
the digastric and removed. The nal view of the resection
demonstrates the hypoglossal nerve, the lingual nerve, and
the transected duct all on the lateral aspect of the hyoglossus
muscle, and the facial artery.
Frozen section analysis is used to check for tumorous
cells and will permit a more comprehensive level I neck dissection if the analysis is positive for suspicious cells. A drain
is inserted and the wound is closed in layers. The sutures are
done with 3-0 Vicryl in the subcutaneous tissue and 5-0
nylon intracutaneous in the skin of the neck.
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Fig. 19.7 Operative site in submandibular gland excision: Wharton’s
duct (1) and the lingual nerve (2) are exposed after dissection and by
downward retraction of the gland (3). The digastric muscle with its
anterior (4a) and posterior (4b) belly is the caudal border of the submandibular triangle and covers the hypoglossal nerve (5); the facial
artery (6) emerges directly medial, and the facial vein (7), lateral to the
posterior digastric belly. The C-shaped mylohyoid muscle (8) forms the
oor of the mouth and separates the cervical part from the oral part of
the submandibular gland, whereas the hyoglossus muscle is posteriorly
located and separates the gland from the pharynx (9). The horizontal
branch of the mandible borders superiorly the submandibular triangle
(10). Adjacent runs the marginal mandibular nerve (11), within the layers of the deep cervical fascia
Tips
• Keep as close as possible to the surface of the submandibular gland to avoid injuring the marginal
mandibular nerve.
• Dissect any tissue around the supercial lobe.
• Ligate facial vessels close to the submandibular
gland.
• Apply forceps to the gland and pull laterally whilst
the bottom of the submandibular gland is freed
from the deep surface of the mylohyoid muscle.
O. Kaschke and M. Schulz-Schönhagen
• Stay very close to the gland around the Wharton’s
duct to avoid irritation of the lingual nerve.
• It is safest to identify the marginal mandibular nerve
by intraoperative neuromonitoring where it crosses
the facial artery and vein, rather than trying to protect the nerve by elevating the vessels.
• To avoid indirect thermal damage, only bipolar cautery should be used next to any nervous structure.
• The hypoglossal nerve is found under the submandibular gland and the Wharton’s duct just above the
tendon of the digastric muscle.
• Salivary stones may be dislocated from the hilus to
the distal Wharton’s duct owing to preparation. If
you are not able to locate and remove them, it is
necessary to trace the Wharton’s duct to the oor of
the mouth. It is sometimes necessary to open the
duct through the oral cavity.
• Because insufciently ligated and divided vessels
can lead to bleeding and subsequent laryngeal
oedema, a double ligature or suturing is recommended to avoid complications.
19.5 Postoperative Care
• The suction drain is left in place for at least 36h, depending on drainage. Remove the drain only if the 24-h cumulative output is less than 30mL.
• An intraoperative single-shot application of an antibiotic
(e.g., amoxicillin) is recommended. Postoperative antibiotic treatment depends on intraoperative ndings or
complications.
• Sutures are removed on postoperative day 7.
Further Reading
Bradley PJ, Guntinas-Lichius O, editors. Salivary gland disorders and
diseases: diagnosis and management. Stuttgart: Thieme; 2011.
Carlson ER, Ord RA, editors. Textbook and color atlas of salivary gland
pathology: diagnosis and management. Wiley-Blackwell: Ames;
2008.
Myers EN, Ferris RL, editors. Salivary gland disorders. NewYork:
Springer Nature; 2007.
Part VIII
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Salivary Gland Surgery: Sublingual Gland Surgery
Intraoral Excision ofRanula
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JohannesJ.Fagan andKevinG.Smith
20.1 Introduction
A simple, or oral, ranula is a salivary pseudocyst consisting
of an extraglandular, extraductal collection of saliva located
in the oor of the mouth; it consequently lacks a true epithelial lining. It typically presents as a soft, submucosal swelling in the oor of the mouth to either side of the midline
(Fig.20.1). The term originates from the Latin word for frog
(rana) as the cyst is said to look like the belly of a frog.
The pathophysiology of ranula has been comprehensively
reviewed by Harrison [1]. It typically develops via mucous
extravasation from the sublingual salivary gland. The
sublingual glands lack a fascial capsule and lie in the areolar
tissue between the oor of the mouth and the mylohyoid
muscle, which has well-described dehiscences. A traumatic
aetiology is supported by frequent observation of rupture of
the duct of Rivinus in pathological specimens, or alternatively,
obstruction of a herniating portion of the gland leading to
acinar rupture [1].
Plunging, or cervical, ranula occurs when the salivary
pseudocyst extends from the oor of the mouth into the submandibular triangle of the neck, either through a defect in the
mylohyoid muscle or, less commonly, by passing behind the
posterior edge of the muscle (Fig.20.2). A ranula may also
track posteriorly along tissue planes into the parapharyngeal
space (Fig.20.3).
The simplest way to clinch the diagnosis is to examine an
aspirate of the cyst. The aspirate is typically thick, syrupy,
straw-coloured saliva (Fig. 20.4) and will test positive for
amylase, a nding distinct from other potential pathologies
J. J. Fagan
Division of Otolaryngology, University of Cape Town, Groote
Schuur Hospital, Observatory, Cape Town, South Africa
e-mail: johannes.fagan@uct.ac.za
K. G. Smith (*)
Department of Otolaryngology - Head and Neck Surgery, North
Shore Hospital, Auckland, New Zealand
e-mail: kevin.smith2@waitematadhb.govt.nz
20
Fig. 20.1 Simple, or oral, ranula
including lymphatic malformations and dysembryogenic
cysts (such as thyroglossal duct, epidermoid, and dermoid
cysts). Imaging of a simple ranula is generally unnecessary
for either diagnosis or surgical planning. In the case of a
plunging ranula, imaging may be helpful to determine the
side of origin where the cervical lesion crosses the midline.
Ultrasound will frequently demonstrate the defect in the
mylohyoid muscle, and, in the hands of a skilled operator, can
demonstrate real-time herniation of the sublingual gland [2].
Simple excision, marsupialisation, and sclerotherapy of
the pseudocyst are all described but are associated with unacceptably high recurrence rates [2–5]. Resection of the ipsilateral sublingual salivary gland has been shown to be effective
for both simple and plunging ranulae, so the remainder of
this chapter focuses on sublingual salivary gland excision
[6]. Transcervical excision of plunging ranulae is presented
in Chap. 21.
© 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_20
199
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Fig. 20.2 Axial CT scan illustrating plunging ranula: intraoral (a) and
cervical (b) components
J. J. Fagan and K. G. Smith
Fig. 20.3 Axial CT scan illustrating ranula extending to parapharyngeal space
Fig. 20.4 Diagnostic aspirate demonstrating syrupy, straw-coloured
saliva
20.2 Preoperative Checklist,
Considerations, andAnaesthesia
• Is it a ranula? The diagnosis is based on the history, clini-
cal appearance, and nature of the aspirate, with imaging
reserved for more complex cases only.
• Which sublingual gland to resect? With large ranulae that
cross the anterior oor of the mouth, it is imperative to
determine the side of origin. Cross-sectional imaging is
helpful in these cases.
• The use of perioperative antibiotics is generally indicated
only for plunging ranulae, to prevent the formation of an
abscess in the cervical component.
• In obtaining consent, caution the patient about the inci-
sion in the anterior oor of the mouth, with the proximity
and risk of injury to the lingual and hypoglossal nerves
and the submandibular salivary duct.
• Surgery is performed under general anaesthesia via a
transoral approach. A nasal endotracheal tube can be
helpful in improving access.
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20.3 Indications
Sublingual salivary gland excision is indicated for a symptomatic oral or plunging ranula.
20.4 Surgical Technique
1. Position the patient supine, sterilise the skin of the anterior neck and lower face, and drape to leave the mouth
and upper neck exposed.
2. Open the mouth with a self-retaining retractor or bite
block, and use a swab-on-a-stick to displace the tongue
posteriorly and to expose the oor of the mouth.
3. Inltrate local anaesthetic with a dental syringe and needle (27–30G) into the oor of mouth, in an immediately
submucosal plane, to minimise bleeding.
4. Incise the mucosa over the ranula in the anterior oor of
the mouth, keeping parallel to and approximately 1cm
from the inner aspect of the mandible, taking care not to
enter the sac.
5. Using sharp and blunt dissection, dissect posteriorly in a
submucosal plane over the ranula.
6. Proceed to dissect anteriorly and expose the sublingual
gland. The gland is surprisingly large and is located
immediately deep to the mucosa just anterior to the submandibular duct (Fig.20.5).
7. As the dissection proceeds, the surgeon should visualise
the lingual nerve and the submandibular duct located
anteriorly (Fig. 20.6). More posteriorly, the distal
branches of the hypoglossal nerve and thin-walled ranine
veins all come into view. Take care not to injure any of
these structures.
8. Dissect the sublingual salivary gland from the submandibular duct to complete the excision. Posterolaterally, it
may be difcult to determine exactly where the sublingual gland ends and the intraoral component of the submandibular gland begins.
9. In cases of plunging ranula, the cervical component
should be aspirated to reduce the chances of abscess formation. This aspiration can be performed transcutaneously, but if the nature of the secretions makes this
difcult, aspiration is also possible transorally by passing a Yankauer suction tip through the defect in the
mylohyoid muscle once the sublingual gland is
delivered.
10. If the submandibular duct is injured, simply translocate
it to the lateral oor of the mouth by dividing the duct
distally, mobilising the duct, and passing it through a
stab incision in the mucosa of the lateral oor of the
mouth, securing it to the mucosa with a suture passed
through the side of the duct (Fig.20.7).
11. If possible, appose the mucosa of the oor of the mouth
with absorbable sutures to hasten healing.
Fig. 20.5 Sublingual gland being dissected, with countertraction provided by a swab-on-a-stick
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Fig. 20.6 Submandibular duct and lingual nerve clearly displaced following sublingual gland removal
J. J. Fagan and K. G. Smith
Fig. 20.7 Submandibular duct transposed to right lateral oor of mouth and sutured to mucosa with a Vicryl suture
20.5 Postoperative Care
Most patients require only simple analgesia. A liquid or soft
diet can be commenced immediately on the day of surgery,
and progressed as tolerated. Antiseptic mouthwashes may be
used in the rst few days after surgery.
References
1. Harrison JD.Modern management and pathophysiology of ranula:
literature review. Head Neck. 2010;32:1310–20.
2. Samant S, Morton RP, Ahmad Z.Surgery for plunging ranula: the lesson not yet learned? Eur Arch Otorhinolaryngol. 2011;268:1513–8.
3. Huang SF, Liao CT, Chin SC, Chen IH.Transoral approach for plunging ranula—10-year experience. Laryngoscope. 2010;120:53–7.
4. Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580
ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2004;98:281–7.
5. Rho MH, Kim DW, Kwon JS, Lee SW, Sung YS, Song YK, etal.
OK-432 sclerotherapy of plunging ranula in 21 patients: it can be
a substitute for surgery. AJNR Am J Neuroradiol. 2006;27:1090–5.
6. Fagan JJ. Ranula and sublingual salivary gland excision. In:
Open access atlas of otolaryngology, head & neck operative surgery. https://vula.uct.ac.za/access/content/group/ba5fb1bd- be95-
48e5- 81be- 586fbaeba29d/Ranula%20and%20sublingual%20
salivary%20gland%20excision.pdf. Accessed 1 Nov 2018.
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