Submandibular Gland Surgery
Submandibular gland excision is a major surgical procedure to remove the submandibular gland (Area C) which is one of 2 major salivary glands found in the human body, the other being the parotid gland (Area B). The most common reason to remove this gland is due to recurrent infections and/or blockages causing swelling as well as an abnormal mass contained within.
Submandibular gland infections as well as blockages inside the gland cause it to swell up resulting in pain and discomfort, esp around the time when one eats when salivary production increases. Why? The best way to think of the salivary gland is a cluster of grapes with the "stem" being the duct through which saliva produced by the "grapes" travels into the mouth. When there is a blockage, there is backflow resulting in accumulation of saliva behind the blockage. When this occurs, the salivary gland swells in size. Over time (as in between meals), the body re-absorbs the access saliva and the gland shrinks back down until the next meal which again triggers the gland to produce more saliva resulting in swelling (again).
Initial (non-surgical) treatment is as follows:
- Apply warm compresses to the enlarged area two to three times a day. After applying the warm compress, massage the gland and swollen areas. Massage in a downward motion working it towards the mouth.
- Suck on hard sour candy, such as lemon drops or tarts continuously. Such candy stimulates salivary production.
- Increase your plain water intake to at least two quarts a day. Try to eliminate caffeine; it works as a diuretic and can dehydrate the body.
- The gland may or may not be infected. If infected, the doctor will prescribe an antibiotic usually for as long as 3 weeks. Use the antibiotic as directed, and complete the full course even if symptoms subside
Over a period of 3-4 weeks, the gland slowly goes back to normal. If such conservative measures do not help, surgical removal is the next step to take.
If a mass is present, it doesn't change in size nor does it ever disappear. Unlike a blockage, the swelling due to a mass does not fluctuate whether you eat or not. Most masses that develop in the submandibular gland are due to benign tumors such as a pleomorphic adenoma or warthin's tumor. These are generally painless and move around easily when manipulated. Even if benign, these tumors should be removed as they will NOT go away on their own and will continue to increase in size over time causing disfigurement. Usually over decades, these benign tumors may also become cancerous (carcinoma ex pleomorphic adenoma).
Unfortunately, some masses can be cancerous and include mucoepidermoid carcinoma, acinic cell carcinoma, as well as metastases from skin cancer (squamous cell carcinoma being the most common). If there is pain, numbness over the chin/teeth/tongue/mouth or facial paralysis, the likelihood of the mass being cancerous increases signficantly.
Typically, the workup of a submandibular gland mass includes a CT scan with contrast of the face as well as fine needle aspiration (FNA) of the mass itself. Obtaining an FNA is helpful in determining the extent of surgical excision required. If malignancy is found, a more extensive surgical procedure is required involving the complete removal of the gland as well as surrounding lymph nodes (neck dissection).
A common concern patients express about this surgery is whether this will affect their salivary production. The blunt answer is NO.
The Surgery Explained
In cases where there is a stone present, one option to try prior to removing the whole gland itself is a procedure called sialolithotomy. In essence, the duct is opened up such that only the stone itself is removed. If the stone is near the duct opening, this procedure can be performed in the office under local anesthesia.
If the stone is located more than 1.5 cm away from the duct opening, the procedure should ideally be done in the operating room under general anesthesia. In this scenario, a small catheter is usually left in place to prevent the duct from scarring shut and removed about 5 days later.
Risks of this procedure include infection and bleeding. More uniquely to this procedure is the risk of duct scarring resulting in recurrent gland swelling. There is also a small risk of numbness to the floor of mouth region.
Submandibular Gland Excision
In cases where sialolithotomy is not an option or if there is an actual mass present, the entire gland is removed. This is accomplished by making an incision about 1 inch below the jawline about 2 inches in length. Dissection is carefully carried out down towards the gland which is than removed carefully while avoiding any important structures. The wound is than closed over a drain. The whole operation takes about 1-2 hours to perform.
Depending on how the surgery goes and how healthy the patient is to begin with, the patient may be able to go home the same day or the next day. The surgical drain is removed usually within 3 days and the sutures 5-7 days after surgery. Pain is not that bad after this surgery with most people requiring narcotics only during the first week. The patient is able to eat whatever they want but is forbidden from any exercise or heavy lifting the first 1-2 weeks after surgery.
Risks of surgery include bleeding and infection which is true for any type of surgery. However, the unique risks for submandibular gland excision include permanent lip paralysis, permanent tongue paralysis, and numbness to the lower part of the mouth. Why is that? It's because the nerves that go to the lip, tongue, and floor of mouth all go through the submandibular gland region and is at risk of getting damaged.
Sometimes, there may be temporary nerve damage and function may return with time (weeks to months), but sometimes it may never return.
We do not offer this procedure, but in essence, the above operations are performed under endoscopy resulting in minimal (if any) incisions to the mouth/neck. For more information, click here.
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