OtolaryngologyHead and Neck Surgery (2008) 139, 530-534

ORIGINAL RESEARCH GENERAL OTOLARYNGOLOGY

Surgical results of the intraoral

removal of the submandibular gland
Ki Hwan Hong, MD, and Yun Su Yang, MD, Chonju, Chonbuk, Korea
OBJECTIVES: Most patients with benign submandibular disorders have been treated surgically without difficulty via the transcervical approach. An alternative to the standard transcervical
approach has been reported such as an intraoral approach.
SUBJECTS AND METHODS: Retrospective chart review of
the 77 patients with benign submandibular disorders. All patients
underwent an excision of the submandibular gland via intraoral
approach.
RESULTS: Early postoperative complications developed in
74.0% of the temporary lingual sensory paresis followed by 70.1%
of temporary limitation of tongue movement. However, these
complications soon resolved in all patients spontaneously. Two
cases of postoperative bleeding and 1 case of abscess formation
were developed. Whereas late complications developed in 4 cases
of residual salivary gland and abnormal sense of mouth floor and
1 case of gustatory sweating (Freys) syndrome.
CONCLUSION: The major advantages of this approach are no
external scar, no injury to the marginal mandibular nerve. The
disadvantage is a more difficult dissection to transcervical approach before proper expert, especially in the severe adhesion of
salivary gland to surrounding tissue.
2008 American Academy of OtolaryngologyHead and Neck
Surgery Foundation. All rights reserved.

hronic inflammatory reaction of the submandibular

gland often results in irreversible histologic changes of
salivary tissue. These conditions may require removal of the
submandibular gland.1-3 The transcervical approach for
these disorders is generally accepted, but this approach has
several complications, such as a residual Whartons duct
inflammation, a residual cyst in the floor of the mouth, and
neurologic complications.4-6 Actually the Whartons duct
could be not totally removed via the transcervical approach.
The residual cyst after transcervical removal of the submandibular gland resulted from the genesis of mucocele due to
injury of the sublingual gland or a mucous retention cyst
due to the obliteration of the sublingual duct. The injury of
the marginal mandibular nerve is a most common complication in the transcervical approach. It consists of a temporary or permanent paralysis mainly due to compression
and/or stretching of the marginal mandibular nerve. The

temporary paralysis resolves spontaneously within a period

of 3 months. The hypoglossal nerve injury is rare in the
transcervical removal of the submandibular gland. When
the hypoglossal nerve is intact, the tongue movement should
be normal neurologically. However, some patients with the
transcervical approach temporarily showed a mild limited
movement of the tongue due to swelling of the floor of the
mouth and/or injury to the extrinsic tongue muscle. This
symptom completely resolved itself within the first week
after surgery.
In the literature review, since Downton and Qvist7 first
reported an intraoral approach for chronic sialadenitis of the
submandibular gland in 1960, no further reports have been
found until the Hong and Kim8 report. Downton and Qvist7
made the incision on the lingual side of the necks of the
teeth when the molar teeth were present. In the edentulous
patients, a curved incision was made through the periosteum
along the alveolus from the retromolar pad to the canine
region. In their procedure, the mucoperiosteum was reflected medially, and the mylohyoid muscle was separated
from its attachment to the mandible. However, Hong and
Kim8 incised the mucosa on the floor of the mouth along the
Whartons duct when the molar teeth were present, and a
more lateral incision was made in the edentulous patients.
The periosteal incision and separation of the mylohyoid
muscle from the mandible are not necessary. Downton and
Qvist7 suggested that the surgery was more difficult when
the molar teeth were present, and it was sometimes necessary to make a small cervical incision simultaneously. In the
Hong and Kim intraoral approach, an additional cervical
incision is not necessary when the molar teeth are present.
However, in the chronically inflamed disorders of the submandibular gland, the intraoral dissection of the gland is
hardly performed due to the severe adhesion to the surrounding tissue, and this may alter the approach to the
transcervical route.
In this study, we evaluated the surgical results associated
with the intraoral approach in a series of 77 operations for
chronic sialadenitis and benign mixed tumors in the submandibular gland.

Received May 11, 2007; revised January 7, 2008; accepted January 23,
2008.

0194-5998/$34.00 2008 American Academy of OtolaryngologyHead and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2008.01.008

Hong and Yang

Surgical results of the intraoral . . .

531

SUBJECTS
The age, sex, postoperative complications and long-term
morbidity of 77 patients with benign submandibular disorders were reviewed for the 10 years since 1997. The simple
intraoral stone removal was not included and bilateral procedures were not performed. An Institutional Review Board
is not available in our institution, but we obtained proper
consent from the patients in keeping with the mandate of the
Declaration of Helsinki. The studys aim, methods, and all
potential risks and benefits to each patient were explained as
part of the consent process. All subjects were informed of
their right to abstain from participation in the study. No
potential subjects were found to be legally incompetent.

SURGICAL TECHNIQUE
After transnasal intubation and proper oral preparation with
hydrogen dioxide and saline irrigation, the incision should
be made through the mucosa of the lateral floor of the mouth
from the orifice of the Whartons duct to the lingual side of
the retromolar region (Fig 1). The sublingual gland is then
dissected and totally removed with the isolation of the
Whartons duct and preservation of the lingual nerve (Figs
2 and 3). The duct should be cut and ligated at the orifice of
Whartons duct. The duct is isolated along the lingual nerve
to the hilum of the submandibular gland. The submandibular ganglion, lying immediately inferior to the lingual nerve,
can be noted by blunt dissection of the gland capsule from
the surrounding tissue. With medial retraction of the tongue
and floor of the mouth including the lingual nerve and
lateral retraction of the mylohyoid muscle, the submandibular gland should be visible. The gland is exposed more
prominently by digital pressure applied beneath the lower
border of the mandible (Fig 4). For good exposure and
lighting of the surgical field, the fiberoptic retractor should

Figure 1

Mucosal incision on the floor of mouth.

Figure 2 Lingual nerve and Whartons duct after total removal

of the sublingual gland.

be used. The gland should be gripped with long tissue

forceps or tonsil hemostatic forceps, dissected with the
tonsil dissector or dissecting scissors, and pulled up through
the incision. The loop of the facial artery and arterial
branches to the gland are noted by blunt dissection and can
frequently be freed completely from the gland. The artery to
the submandibular gland should always be ligated or
clipped with a hemoclip to prevent severe bleeding during
dissection and postoperative hematoma. After removal of
the submandibular gland, the hypoglossal nerve should be
identified in the bed of the surgical field, and bimanual
palpation should be applied to detect residual gland in the
submandibular space. The incised mucosa is then sutured
back loosely with silk sutures. A suction drain is inserted
through the intraoral incision site and removed the first or
second postoperative day according to the drain output.

Figure 3 Uncrossing the Whartons duct from lingual nerve

submandibular gland.

532

OtolaryngologyHead and Neck Surgery, Vol 139, No 4, October 2008

Table 2
Complications after submandibular gland excision
Complications

Figure 4 Dissection of submandibular gland with digital pressure and identification of facial artery or its branch to the submandibular gland.

RESULTS
Thirty-four (44%) patients were male and 43 (56%) were
female; the male to female ratio was 1: 1.2 (Table 1). The
age of the patients ranged between 13 and 67 years, with a
mean age of 36.4 years. The final diagnosis of sialolithiasis,
based on the observation of sialoliths by the surgeon and/or
the pathologist, was established in 47 (61.0%) cases. A
previous intraoral stone removal had been performed in 9
(19%) cases among the patients with a stone. A total of 20
(25.9%) cases of sialadenitis without a stone were classified
as chronic sialoadenitis. Nine (11.7%) cases of benign pleomorphic adenomas were also treated via the intraoral approach.
As shown in Table 2, early postoperative complications
were observed in most of the patients. A temporary lingual
nerve injury (such as paresthesia of the tongue) in 57
(74.01%) cases resolved within 3 to 4 weeks in all cases; a
mild limited movement of the tongue in 54 (70.1%) cases
resolved within 4-6 weeks except for 2 cases. 2 cases of
wound bleeding, and 2 cases of abscess formation. Late
postoperative complications after 3 months appeared as

Table 1
Distributions of submandibular disorder
Diagnosis
Chronic sialoadenitis with stone
Chronic sialoadenitis
Pleomorphic adenoma
Chronic sialoadenitis with ranula
Total
Age ranged from 13 to 67 years.
Sex distributions: male 34, female 43.

Number (%)
47
20
9
1
77

(61.0)
(25.9)
(11.7)
(1.3)
(100)

Early complications
Infection (abscess)
Bleeding
Limited tongue motion
Late complication
Residual duct
inflammation
Residual salivary tissue
Unaesthetic scar
Gustatory sweating
Neurologic
complications
Mandibular nerve,
temporal
permanent
Lingual nerve, temporal
permanent
Hypoglossal nerve,
temporal
permanent

Transcervical*

Intraoral
(%)

7.3
3.8
?

2 (2.6)
2 (2.6)
54 (70.1)

7.3
?
4.8
0.5

0
4 (5.2)
0
1 (1.3)

11.6
7.7
4.4
1.4

0
0
57 (74.0)
0

3.4
2.9

0
0

*Berini-Aytes and Gay-Escoda cases, 251 patients involved.

Hong and Kim cases, 77 patients involved.

follows: 4 cases of lingual paresthesia that were tolerable in

all patients and resolved later, 2 cases of asymmetry of the
tongue movement that were not symptomatic and only
physically noted, and 4 cases of the residual salivary tissue
palpated on the neck. Gustatory sweating symptom (Freys
syndrome) was observed in 1 case. No residual inflammation in the Whartons duct and no external scar were noted.
No injuries of the hypoglossal or marginal mandibular
nerves were noted.

DISCUSSION
On the surgical approach for the benign submandibular
disorders, the transcervical approach is widely accepted and
relatively simple, and the salivary gland tissue could be
removed without difficulty and without alteration of the
salivary system. However, the transcervical procedure has
frequently been associated with neurologic complications
after surgery, including the marginal mandibular nerve and
lingual and hypoglossal nerves. Alternative surgical approaches have been developed to avoid neurologic risks and
visible scarring in the upper neck. Hong and Kim8 reported
a new surgical approach for intraoral removal of benign
submandibular disorders and suggested that the intraoral
approach could be extended as an alternative to the transcervical approach. However, this approach has also a few
problems, such as temporal sensory paresis and limited
movement of tongue, but resolved spontaneously, and in the

Hong and Yang

Surgical results of the intraoral . . .

severe adhesion to surrounding tissue the intraoral dissection of gland is not easily dissected. Recently, to improve
cosmetic results, minimally invasive endoscopic and endorobotic methods of submandibular gland resection through
various routes have been assessed in experimental9-11 and
clinical studies.12,13 The operation time of endoscopic surgery, however, is significantly longer than that of other
procedures.
On retrospective review of the surgical data during our
study period, only 11 patients were treated via the transcervical approach for the benign disorders of submandibular
gland. Except for an external scar, they did not show any
definite sequelae, including neurologic defects of lingual
and hypoglossal nerves. Some patients showed a little
asymmetry of the lower lip due to cutting of the plastysma
muscle of the submandibular area; they recovered normally
and were not symptomatic at all. In our study, the intraoral
procedure for submandibular excision has also minor complications after surgery. Two cases of bleeding and 3 cases
of infected abscess were noted. During dissection of the
submandibular gland via the transcervical route, the loop of
the facial artery or arterial branches to the gland should be
easily noted and could frequently be freed completely from
the gland. However, to demonstrate and ligate the artery to
the submandibular gland in the intraoral approach may not
be easy without sufficient experience.8 Experience and a
detailed knowledge of the anatomy for proper dissection
could reduce bleeding. In our 2 cases of postoperative
bleeding, the submandibular area and floor of the mouth
swelled up immediately after surgery. Bleeding was controlled during an urgent procedure in the operating room
under general anesthesia. The bleeding points were
branches of the facial artery and were controlled via the
transcervical route in 1 patient and the intraoral route in the
other patient.
The intraoral approach may offer more chances for contamination from the oral cavity to the submandibular space.
However, with proper preoperative preparation and continuous suction drainage with the hemovac through the oral
cavity after dissection, an infection is preventable. In this
intraoral approach the hypoglossal nerve should be identified at all times and never injured, but mild limitation of
tongue movement was noted also with 70 percent of the
patients. The swelling of the lateral tongue and floor of the
mouth was observed on physical examination and resulted
in temporary limited tongue movement and articulation difficulty during speech. This resolved itself within 2 weeks.
However, in 2 cases, a slight limitation of tongue movement
was noted physically, but not symptomatically, due to scar
contracture on the floor of the mouth.
The residual duct inflammation could be noted in 3
percent to 12 percent of the patients as late complications of
the transcervical approach.4,14,17 The Whartons duct could
not be removed completely in the transcervical approach,
but with the intraoral approach the duct can be completely
removed because the duct is cut and ligated at the orifice.

533
Therefore, the residual duct inflammation was not observed
in this intraoral approach. The cause of a residual cyst in the
mouth floor after the transcervical removal of the submandibular gland can be explained by the genesis of mucoceles
due to injury of the sublingual gland or mucous retention
cysts due to obliteration of the ducts of Rivinus. An incidence of a residual cyst can be up to 6 percent.14 This cyst
can be observed mainly in the anterior floor of mouth, but
sometimes in the posterior floor of mouth. In the intraoral
approach, the sublingual gland should be removed totally
for a proper surgical field; dissection of the submandibular
gland and the residual cyst does not occur in this approach.
During the transcervical dissection of the submandibular
gland, the salivary tissue may be removed completely, but a
small amount of salivary tissue could be left. A small
amount of salivary tissue may not induce the clinical problems because of atrophy of salivary tissue.15 However, in
this study, 3 patients showed a small palpable mass on the
submandibular area 6 months after surgery. One patients
mass decreased and clinically caused no problems, but 2
patients showed a protruded and reddish mass on the skin.
The masses were removed via a small incision on the neck
skin and showed up as salivary tissue pathologically. On
retrospective review, these 3 patients underwent surgery in
the beginning of our intraoral experience; at that time we
were inexperienced. However, with experience, we improved our surgical technique to remove all submandibular
tissue, and no further residual salivary tissue was noted.
As to the aesthetic problem, the transcervical incision
may induce a scar problem, especially in young women or
keloid characters. However, a major advantage of this approach is the avoidance of external scarring, especially in
young patients or keloid characters. The submandibular area
involved appears as a little dimpling, but not distinct externally in most patients.
As to neurologic complications, an injury of the mandibular branch of the facial nerve is the most common complication in the transcervical approach. Milton et al16 reported an 18 percent incidence of damage to the marginal
mandibular nerve; 7 percent were permanent. It usually
consists of a temporary paralysis due to a compression
and/or stretching injury, which can resolve spontaneously
within a period of 3 months.17 However, in the intraoral
approach, the marginal mandibular nerve is not exposed
during dissection, and there is no possibility of the facial
nerve injury. This is also a major distinct advantage of the
intraoral approach. In the transcervical approach, the lingual
nerve should always be identified. Lesions associated with
this nerve are not common, and if they do occur, they are
temporary. A 3 percent incidence of permanent neurologic
deficit was described by Milton et al,16 while Turco et al18
reported alterations of lingual sensitivity in 6 percent of
cases. Goudal and Bertrand14 reported that 12 percent of the
patients in their study presented neurologic sequelae, but
only 4.8 percent of these were permanent. This incidence
would have been higher if systematic examination had been

534

OtolaryngologyHead and Neck Surgery, Vol 139, No 4, October 2008

carried out. However, in the intraoral approach, the lingual

nerve is always compressed and/or stretched during traction
of the floor of mouth, and the neurologic problem of lingual
nerve injury was observed in most patients temporarily.
Most patients showed temporary injury that lasted 2 to 3
weeks along the side of the tongue. Four patients complained of a mild reduced sense of the tongue that lasted 3
months after surgery, but resolved by long-term follow-up.
The hypoglossal nerve is a critical structure that should be
identified at all times3,5 in the transcervical approach and in
the intraoral approach.8 The incidence of this nerve injury is
rare, about 1 percent, in the transcervical approach,13 but
not observed at all in the intraoral approach. Berini-Aytes
and Gay-Escoda4 reported 1 case of the gustatory sweating
syndrome, which resolved spontaneously. In other series,
this syndrome also occurred exceptionally.16,19 In this intraoral approach, 1 case of the gustatory sweating syndrome
occurred. The avoidance of this syndrome has been one of
the motives cited in support of the preservation of the
submandibular ganglion of the lingual nerve.15,20

CONCLUSION
This intraoral approach could be extended as an alternative
to the transcervical approach. The major advantages of this
approach are the avoidance of an external scar and of injury
to the mandibular branch of the facial nerve or the hypoglossal nerve. However, most patients temporarily complained of neurologic problems of the lingual nerve, but
these were completely resolved within at least 2 months
after surgery. In the severely adhered salivary gland, the
intraoral dissection may not be possible, in which case, the
surgical method should be altered to the complementary
transcervical excision. The arterial branches to the submandibular gland should always be ligated for prevention of
bleeding.

AUTHOR INFORMATION
From the Department of OtolaryngologyHead and Neck Surgery, Chonbuk National University, Medical School, Chonju, Chonbuk, 561-712,
Korea.
Corresponding author: Ki Hwan Hong, MD, Department of Otolaryngology
Head and Neck Surgery, Chonbuk National University, Medical School
Chonju, Chonbuk, 560-182, Republic of Korea.
E-mail address: khhong@chonbuk.ac.kr.

AUTHOR CONTRIBUTION
Ki Hwan Hong, study design and writer; Yun Su Yang, data collection.

FINANCIAL DISCLOSURE
None.

REFERENCES
1. van den Akker HP, Besemann-Sokole E. Submandibular gland function following transoral sialolithectomy. Oral Surg 1983;56:351 6.
2. Isacsson G, Isberg A, Haverling M, et al. Salivary calculi and chronic
sialoadenitis of the submandibular gland: a radiographic and histologic
study. Oral Surg 1984;58:6227.
3. Beahrs OH, Woolner LB. Surgical treatment of diseases of salivary
gland. Oral Surg 1969;27:119 28.
4. Berini-Aytes L, Gay-Escoda C. Morbidity associated with removal of
the submandibular gland. J Craniomaxillofac Surg 1992;20:216 9.
5. Eichel BS, Bray DA, Kaplan HJ, et al. The overall management of
salivary gland disorders. Laryngoscope 1981;91:504 11.
6. Blatt I. Inflammation of the salivary glands. Laryngoscope 1966;76:
91733.
7. Downton D, Qvist G. Intraoral excision of the submandibular gland.
Proceedings of the Royal Society of Medicine 1960;53:543 4.
8. Hong KH, Kim YK. Intraoral removal of the submandibular gland: a new
surgical approach. Otolaryngol Head Neck Surg 2000;122:798 802.
9. Monfared Y, Saenz Y, Terris DJ. Endoscopic resection of the
submandibular gland in a porcine model. Laryngoscope 2002;112:
1089 93.
10. Guyot L, Duroure F, Richard O, et al. Submandibular gland endoscopic resection: a cadaveric study. Int J Oral Maxillofac Surg 2005;
34:40710.
11. Terris DJ, Haus BM, Gourin CG, et al. Endo-robotic resection of the
submandibular gland in a cadaver model. Head Neck 2005;27:946 51.
12. Chen MK, Su CC, Tsai YL, et al. Minimally invasive endoscopic
resection of the submandibular gland: a new approach. Head Neck
2006;28:1014 7.
13. Roh JL. Removal of the submandibular gland by a retroauricular
approach. Arch Otolaryngol Head Neck Surg 2006;132:7837.
14. Goudal JY, Bertrand JC. [Complications of surgical treatment for
submandibular calculi]. Rev Stomatol Chir Maxillofac 1979;80:
349 50.
15. Yoel J. Pathology and surgery of the salivary glands, 3rd ed. Springfield, IL: Charles C Thomas Publisher; 1975. pp. 820 1136.
16. Milton CM, Thomas BM, Bikerton RC. Morbidity study of submandibular gland excision. Ann R Coll Surg Engl 1986;68:148 50.
17. Marynard J. Contemporary surgery: submandibular and parotid resection. Br J Hosp Med 1978;20:70.
18. Turco C, Nision A, Brunetti F. [Submandibular sialoadenectomy and
long-term results]. Minerva Stomatol 1988;37:329 33.
19. Bailey BM, Pearce DE. Gustatory sweating following submandibular
salivary gland removal. Br Dent J 1985;158:17 8.
20. Rankow RM, Polayes IM. Inflammatory disorders. Surgical management. In: Rankow and Polayes: Diseases of the salivary glands. Philadelphia: WB Saunders; 1976. pp. 229-38.