5

SALIVARY GLAND
SURGERY
R. BRUCE DONOFF, D.M.D., M.D.
SALIVARY GLAND SURGERY 59
MINOR SALIVARY GLANDS
Indications

The major indication for surgery of the minor

salivary glands is obstructive disease due to a mu-
cocele or ranula. Tumors of the minor salivary glands
are also indications for surgery. They occur primarily
in the palate and buccal mucosa. Diagnosis must
exclude the possibility of a maxillary sinus tumor
appearing as a palatal mass. Computed tomography
(CT) scan or tomograms of the hard palate are helpful
in this regard.
Approach
The surgical approach for a mucocele involves
excision of the retention cyst and minor glands in the
immediate area. For a ranula the approach is
exteriorization by marsupialization (Fig. 5-1).
SUBLINGUAL GLAND
Indications
The sublingual gland infrequently requires exci-
sion. A recurrent ranula that has failed several at-
tempts at marsupialization should be considered
such an indication. Infrequently, tumors of the sub-
lingual gland occur and require removal of the gland
and possibly more radical surgery depending on the
histology of the tumor.
Approach
The approach to the gland is transoral with an
assistant pushing up beneath the gland for better
exposure. The procedure is best done under general
anesthesia. Care must be taken to maintain Whar-
ton's duct and the lingual nerve. Placement of a
lacrimal duct probe in the duct facilitates its identi-
fication during surgery.
60 SALIVARY GLAND SURGERY
SUBMAXILLARY GLAND
Indications
The main indication for removal of the submaxil-
lary gland is recurrent infections secondary to stone
obstruction. In these cases the stone is too proximal to
be obtained transorally. Sometimes the offending
stone is directly at the hilum of the gland. Another
indication, although less common, is tumor in the
parenchyma of the submaxillary gland. In general the
occurrence of a tumor in this gland carries a greater
chance of malignancy. The general rule is the smaller
the salivary gland involved with tumor the greater the
chance of the tumor being malignant. This rule does
not hold true for tumors of the minor salivary glands,
however.
Approach
The approach to the gland is extraoral via a sub-
mandibular approach (Fig. 5-2). An incision is made
two fingerbreadths below the inferior border of the
mandible. The dissection identifies the duct coursing
behind and above the mylohyoid muscle into the
mouth (Fig. 5-3). The duct is double ligated with 2-0
silk suture. ":'!
PAROTID GLAND—SUPERFICIAL
PAROTIDECTOMY
Indications
The major indication for superficial parotidectomy
is tumor in the gland. The most common is pleo-
morphic adenoma. CT scan evaluation should exclude
deep parotid lobe involvement preoperatively.
Occasionally the operation is indicated for massive
enlargement secondary to Sjogren's syndrome or a
stone in the hilum of the gland. In the latter case, the
stone may be removed from Stensen's duct without
gland removal.
Approach
A combined preauricular and submandibular inci-
sion is used with development of a flap to expose the
gland and tumor (Fig. 5-4). The sternocleido-mastoid
muscle (SCM) is followed superiorly to find the main
facial nerve trunk (Fig. 5-5, arrow). On occasion this
route is unsuccessful and a peripheral branch, usually
the marginal mandibular, may be found and traced
proximally. A completed dissectiori with preservation
of the facial nerve is shown in Figure 5-6. The wound
is closed over a drain in layers. A fluffy pressure
dressing is used with protection of the ear cartilage.
INTRAOPERATIVE
COMPLICATIONS
If during submaxillary gland extirpation the lingual
and/or hypoglossal nerve is adherent to the medial
side of the gland it must be dissected free.
If during marsupialization of a ranula violation of
Wharton's duct occurs, the use of a plastic cannula as
a stent is helpful. A lacrimal duct probe may be used
in the duct to delineate the structure.
Malignant tumor in the facial nerve requires resec-
tion of that portion of nerve. The decision regarding
immediate nerve grafting depends on the extent of
tumor invasion and the general size and history of the
lesion.
POSTOPERATIVE
COMPLICATIONS
Facial nerve weakness may occur even if the dis-
section of the nerve has been meticulous. Upper
eyelid weakness may necessitate patching of the eye
in order to prevent corneal abrasion.
Prey's syndrome, or auriculotemporal syndrome,
occurs uncommonly. There is no treatment. Ear
numbness secondary to greater auricular sacrifice is
best explained preoperatively to the patient.
SALIVARY GLAND SURGERY 61
62 SALIVARY GLAND SURGERY KEY

REFERENCES Mason, O.K., Chisholm, D.M.: Salivary Glands in Health and

Disease. Philadelphia, W.B. Saunders Co., 1975.
Gorlin, R.J., Goldman, H.M. (eds.): Thoma's Oral Surgery, 6th ed. Moutsopolous, H.M., et al.: Sjogren's syndrome: Current issues.
St. Louis, C.V. Mosby, 1970. Ann Intern Med 92:212, 1980.