Professional Documents
Culture Documents
Submandibular Gland Excision PDF
Submandibular Gland Excision PDF
The submandibular salivary gland (SMG) The digastric muscle forms the
may be excised for chronic sialadenitis, anteroinferior and posteroinferior
sialectasis, sialolithiasis, benign and boundaries of the submandibular triangle
malignant tumours, and as part of a neck (Figure 2). It is an important surgical
dissection. The use of sialendoscopy is landmark as there are no important
likely to reduce the frequency of SMG structures lateral to the muscle. The facial
excision for sialolithiasis. artery emerges from immediately medial to
the posterior belly, and the XIIn runs
The key concerns for the patient are the immediately deep to the digastric tendon.
surgical scar, and injury to the marginal
mandibular, lingual and hypoglossal The mylohyoid muscle is a flat muscle
nerves. attached to the mylohyoid line on the inner
aspect of the mandible, the body of the
Surgical anatomy hyoid bone, and by a midline raphe to the
opposite muscle (Figures 1, 2, 4, 8). It is a
The SMG has both an oral and cervical key structure when excising the SMG, as it
component. It passes around the posterior forms the floor of the mouth, and separates
free margin of the mylohyoid muscle, the cervical from the oral part of the SMG.
which forms the diaphragm of the mouth Of importance to the surgeon is that there
and separates the cervical and oral are no important vascular or neurological
components of the gland. The SMG is structures superficial to the mylohyoid; the
situated mainly in the submandibular lingual and XIIn are both deep to the
triangle (Level 1b) of the neck. The oral muscle.
component extends some distance along
the submandibular duct immediately deep
to the mucosa of the floor of the mouth
(Figure 1). The duct opens close to the
midline in the anterior floor of mouth.
Posterior belly digastric
Mylohyoid muscle
Figure 1: Superior, intraoral view of SMG, The marginal mandibular nerve is at risk
duct, lingual nerve and mylohyoid and of injury as it runs within the investing
geniohyoid muscles layers of deep cervical fascia overlying the
gland, and may loop up to 3cms below the
The cervical part of the gland is ramus of the mandible. It comprises up to
immediately deep to the platysma, and is 4 parallel running branches. It crosses over
encapsulated by the investing layer of the the facial artery and vein before ascending
deep cervical fascia. to innervate the depressor anguli oris
muscle of the lower lip (Figure 3). In order
to minimise the risk of injury to the nerve,
one should incise skin and platysma at
least 3cms below the mandible, and incise
Lingual nerve
the fascial covering of the SMG just above
the hyoid and do a subcapsular resection of Submandibular ganglion
Nerve to mylohyoid
Mylohyoid muscle
Submandibular gland
2
Submental artery
Mylohyoid muscle
Myohyoid artery
Facial artery
3
Operative steps
Anaesthesia
4
so as to avoid injury to marginal
mandibular nerve.
5
behind the posterior belly of the digastric
Mylohyoid
muscle.
Marg mand n
Lingual n
SM duct
Ant belly of
digastric Facial a
SM ganglion
By retracting the mylohyoid anteriorly and Figure 16: Finger dissection in plane
by using careful finger dissection, the between SMG and fascia covering XIIn
lingual nerve, submandibular ganglion, and and ranine veins
submandibular duct come into view
(Figure 15). Once the XIIn nerve has been identified,
one may safely clamp, divide and ligate the
submandibular duct and the lingual nerve,
Mylohyoid
taking care not to place the tie across the
main nerve (Figure 17). With surgery for
sialolithiasis one should follow and divide
the duct more anteriorly in the floor of the
mouth so as not to leave behind a calculus.
Lingual n
Marg mand n
SM Duct
XIIn
6
and divided where if exits from behind the Alternative technique: Preservation of
posterior belly of digastric (Figure 18). facial artery
Marg mand n
Facial vein
Figure 18: Ligation and division of facial
artery Facial artery
Ant branch
The SMG is then finally freed from the facial artery
tendon and posterior belly of the digastric
and removed. The final view of the Post belly of
digastric
resection demonstrates the XIIn, ranine
veins, lingual nerve, and transected duct all Figure 20: Preserving the facial artery by
on the lateral aspect of the hyoglossus dividing anterior branches
muscle, and the facial artery (Figure 19).
Author & Editor
SM duct