The submandibular gland can be removed through either a transcervical or transoral approach. Key anatomical structures include the marginal mandibular nerve, lingual nerve, hypoglossal nerve, facial artery and vein, and Wharton's duct. The transoral approach has less risk of marginal mandibular nerve injury but a narrower surgical field. Indications for removal include recurrent enlargement, salivary stones, infection, or suspected neoplasm. Care must be taken to identify and preserve nearby nerves and vessels during dissection and removal of the gland.

2. ANATOMY
• Submandibular gland is one of the three paired
salivary glands.
• Size of a walnut
• Mixed gland with predominantly serous in type
• Responsible for about 70% of salivary secretion.

3. ANATOMY
• Situation: Digastric triangle and lodges partly in the
submandibular fossa of the mandible
• Part of gland : Large superficial part Small deep part
continous with each other around the post. Border of
mylohyoid

4. ANATOMY

5. ANATOMY
Whartons duct
• 5 cm long
• Emerges at the anterior end of deep part of
the gland
• Runs forwards on hyoglossus b/w lingual
and hypoglossal N
• At the ant. Border of hyoglossus it is
crossed by lingual nerve
• Opens in the floor of mouth at the side of
frenulum of tongue

6. SURGICAL ANATOMY
The digastric muscle
• forms the anteroinferior and posteroinferior
boundaries of the submandibular triangle.
• It is an important surgical landmark as there
are no important structures lateral to the
muscle.
• The facial artery emerges from immediately
medial to the posterior belly, and the XIIn
runs immediately deep to the digastric
tendon.

7. SURGICAL ANATOMY
Mylohyoid muscle
• key structure when excising the SMG, as it
forms the floor of the mouth, and separates
the cervical from the oral part of the SMG.
• The lingual and XIIn are both deep to the
muscle.

8. SURGICAL ANATOMY
Marginal mandibular nerve
• Is at risk of injury.
• It runs within the investing layers of deep cervical
fascia overlying the gland.
• May loop up to 3cms below the ramus of the
mandible.
• It crosses over the facial artery and vein before
ascending to innervate the depressor anguli oris
muscle of the lower lip.

9. SURGICAL ANATOMY
3 methods of preserving
1. Approaching the gland at the level of hyoid bone, and keeping the
dissection deep to the glands facial covering.
2. Dividing the facial vessels well below the mandible and on lifting up the
upper ligated stumps.
3. Identify tail of parotid where it lies anterior to retromandibular vein and
to trace it forward

10. SURGICAL ANATOMY
lingual nerve
• comes into view during SMG excision when the
SMG is retracted inferiorly, and the mylohyoid is
retracted anteriorly.

11. SURGICAL ANATOMY
Hypoglossal nerve (XIIn)
• Enters the submandibular triangle posteroinferiorly and
medial to the hyoid bone.
• The XIIn is covered by a thin layer of fascia, distinct
from the SMG capsule.
• Accompanied by thin walled ranine veins that are easily
torn at surgery.

12. SURGICAL ANATOMY
Facial artery
• Enters the submandibular triangle
Posteroinferiorly from behind the posterior belly
of digastric and stylohyoid.
• Courses across the posteromedial surface of the
SMG.
• Reappears at the superior aspect of the SMG
where it joins the facial vein to cross the
mandible.

13. Indications
• Repeated enlargement of the gland.
• Salivary gland calculi
• Chronic salivary gland infection.
• Duct stenosis
• Suspected submandibular neoplasm

14. PREOPERATIVE EVALUATION
History
• History of swellings (onset ,duration, recurrence )
• Pain
• Variation with meals
• Bilateral
• Dry mouth
• Radiation history
• Recent operative history

15. Examination : Inspection
• Asymmetry (glands, face, neck)
• Diffuse or focal enlargement
• Erythema
• Trismus
• Medial displacement of structures intraorally
• Cranial nerve examination

16. Examination : Palpation
• Bimanual palpation of floor of mouth in a
posterior to anterior direction.
• Palpation of duct papilla.
• Bimanual palpation of the gland (firm or spongy)
• Palpate for cervical lymhadenopathy

17. INVESTIGTIONS
• Plain X-ray
• Ultrasound
• Sialography
• CT and MRI scanning
• Fine-Needle Aspiration Biopsy

18. LATERAL MANDIBULAR VIEW TRANSORAL OCCLUSAL VIEW

19. Advantage
detects
radiolucent
stones
Disadvantage
• invasive
• bleeding &
perforations
contraindicated
• acute
infections
• allergic to
contrast
Sialography

20. Ultrasound: differntiate between
• solid versus cystic lesion
• Intrinsic from extrinsic

21. CT scan
involvement of the mandible,
 the presence or absence of pathologic
lymphadenopathy
 local extent of the tumor.

22. Fine-Needle Aspiration Biopsy
• Useful tool for differentiating chronic inflammatory disease from neoplasia.

23. Surgical approaches
• Transcervical approach
• Transoral approach

25. Informed Consent
Marginal mandibular nerve>possibility of weakness of the lower lip.
 Lingual > numbness of the tongue
Hypoglossal nerves > paralysis of the tongue on the operated side

26. OPERATION STEPS
Anesthesia
• General anesthesia
• Avoid muscle relaxant to monitor lower lip movement

27. OPERATION STEPS
• Positioning and draping
• Incision
3-4 cm below the mandible or at the level of hyoid
bone

28. • The incision is carried through skin,
subcutaneous tissue and platysma to
expose the capsule of the SMG, the facial
vein and posteriorly, the external jugular
vein

29. • The facial vein is ligated and
divided where it crosses the SMG

30. • The fascial capsule of the SMG is incised
• subcapsular dissection

31. • Dissect bluntly with a hemostat in the
fatty tissue above the gland to identify
the facial artery and vein
• Divide and ligate facial artery and
vein as close as possible to SMG.

32. • Front-to-back mobilisation of SMG off
mylohyoid muscle, and division of
mylohyoid nerve and vessels to gain access
to the posterior border of mylohyoid
muscle

33. • Exposing posterior part of mylohyoid

34. • Retracting mylohyoid brings lingual
nerve, XIIn and submandibular
duct into view

35. • Finger dissection in plane between
SMG and fascia covering XIIn and
ranine veins

36. • Division and ligation of submandibular
duct and submandibular ganglion
• follow and divide the duct more anteriorly if
surgery for sialolithiasis so as not to leave
behind a calculus

37. • The SMG can then be reflected inferiorly,
and the facial artery is identified,
ligated and divided where if exits from
behind the posterior belly of digastric

38. • The SMG is then finally freed from the
tendon and posterior belly of the digastric and
removed

39. • Wound irrigation
• Placement of suction drain
• Wound is closed in layers

40. Post-operative management
• Head end elevation
• NPO for 4-6hours
• Patient observed for airway compromise
• Monitoring of vital signs
• I/V antibiotics
• Analgesics
• Removal of drain after 24-48hrs

41. Complications
• General
• Hematoma
• Infection
• Specific
• Marginal mandibular nerve injury
• Lingual nerve injury
• Hypoglossal nerve injury
• Retained calculi in duct

43. • The submandibular gland can be safely and successfully
removed through an intraoral approach in a select population
of patients with benign pathology

44. Advantages of the transoral approach
• less risk of injury to the marginal mandibular nerve
• Avoidance of an external scar
• Minimal risk of postoperative mucocele formation, or inflammation of
Wharton’s duct

45. Disadvantages
• Narrow surgical field
• Scar contracture in the floor of mouth
• Temporary or permanent restriction of tongue movement,
• Abnormal tongue sensation

46. Contraindication
• Suspected or proven malignancy,
• Extensive scarring from prior abscessed gland
• Surgeon lack of familiarity with the procedure

47. • Nasotracheal intubation
• Injection of lidocaine with epinephrine
• Insertion of a probe into the orifice of
Wharton's duct

48. • An incision is made in the floor of mouth from
the submandibular papilla to the retromolar
trigone.
• A cuff of mucosa on the gingival side is
preserved to allow for tension free closure and
to prevent limitation of tongue mobility due to
scar contracture

49. • The lingual nerve is identified and dissected free of its attachments to the submandibular
duct and gland

50. • The submandibular gland is bluntly
dissected and delivered into the surgical
wound by applying external pressure on
the neck
• Branches of the facial artery and vein are
ligated with care not to disrupt the
marginal mandibular branch of the facial
nerve.

51. • The hypoglossal nerve is identified and
preserved.

52. • The gland is removed
• Wound bed irrigated and closed in a tension free manor