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Submandibular Gland Resection

Unlike in parotid surgery, where only a portion of the gland surrounding a tumor is removed, the entire gland is usually removed in submandibular gland surgery. A submandibular gland resection is the removal of that gland, most often for the removal of a tumor, but it may be performed for benign conditions such as chronic infection secondary to salivary stone.

The submandibular gland is located in Level I of the neck, just underneath the jaw. The duct empties saliva into the floor of mouth. Removal of one submandibular gland does not affect your ability to make saliva in any noticeable way because there are so many other saliva-producing glands.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

You will be put to sleep with general anesthesia for this procedure.

The incision for this procedure is made in the neck, usually within a natural skin crease.

Your surgeon will need to protect a number of important structures when performing this surgery while at the same removing the gland with a rim of normal tissue. The structures that need to be protected include the marginal mandibular nerve, which is a tiny nerve sitting over top of the submandibular gland that is responsible for moving the lip during the act of smiling. The platysma muscle is a broad, flat muscle that also helps to move the lower lip. That muscle is cut in the process of gaining exposure and takes several weeks to recover after closure of the wound. The lingual nerve (sensation to the tongue) and hypoglossal nerve (movement of the half of the tongue) must be protected.

Associated procedures might include a neck dissection. More uncommonly, a more extensive resection to include the mandible or floor of mouth might be required.

At the end of the procedure, your surgeon will probably place a small drain coming out of your skin. This is to drain any blood and/or fluid that might accumulate in the space that is created by removing the submandibular salivary gland. When the time is right (from one to a few days), the drain will be removed by your surgical team. This takes only a few seconds, and you can think of it as removing a bandage. There will be a little discomfort, but it will go by quickly.

Depending on if any additional procedures were done, you will go home the same day or within a few days of the surgery. You should be able to drink and eat very soon after the surgery. There is little pain associated with this procedure, but you will probably be given a little pain medication anyways.

You should be up and out of bed by the same or next day.

Recovery and aftercare

The recovery course will depend on the extent of any additional surgery and reconstruction. With some surgeries you could go home after a few hours of observation in the recovery room; others might require staying in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve. With a submandibular gland excision alone, you should be able to leave the hospital the same day or within two to three days at most.

If you do stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital (with or without visiting nurses or home care), others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

The risks of submandibular gland resection include, but are not limited to: 

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Seroma: This is a collection of normal body fluid in the neck, after removal of the drain. This can be treated with observation, as the body will eventually resorb it, or repeated needle aspirations. The risk of leaving seroma is that it could become infected.
  • Infection: Neck dissections are done under completely sterile conditions. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Sialocele: This is a collection of saliva under the skin. This can occur because a cut end of the submandibular salivary gland might continue to make saliva. It will manifest as a fluid-filled swelling somewhere near the surgical site and gets bigger with eating. Treatment can include doing nothing, applying a pressure dressing or repeated aspirations to draw off the saliva. Sialoecele after submandibular gland surgery is much less common than after parotid gland surgery.
  • Sensory disturbance to the tongue: The lingual nerve runs in the submandibular triangle just under the mylohyoid muscle. The submandibular ganglion comes off of the lingual nerve and must be divided to remove the gland. If not careful, or if cancer extends to the lingual nerve, it might need to be sacrificed. This will result in a loss of feeling on that side of the tongue.
  • Problems with tongue movement: The hypoglossal nerve (Cranial Nerve XII) can rarely be injured or sacrificed. This will result in an inability to move half of the tongue. When you are asked to stick your tongue straight out, the tongue will veer to the side of the cut nerve.
  • Facial nerve injury: This is an important risk of submandibular gland resection but is limited to one of the major branches of the facial nerve called the marginal mandibular nerve. Injury to this nerve will manifest as inability to move that side of the lower lip. Over time, the muscles in that region might atrophy, leaving an obvious asymmetry at rest. Usually, it is more pronounced when performing the act of smiling. Loss of function of the marginal mandibular branch of the facial nerve is most evident when a patient tries to pucker the lips. It is also evident during a full smile when the affected side does not move downward as much as the normal side. Weakness of these muscles after the surgery can be temporary (if the nerve is just stretched) or permanent (if the nerve is cut). This can be prevented by meticulous surgical skill; but in some cases, especially if the nerve goes directly through the cancerous tumor, this branch of the facial nerve might have to be sacrificed. Facial reanimation procedures to improve appearance might be undertaken in the future.