Removal of the submandibular gland by a submental approach: A prospective, randomized, controlled study

Summary

There are few controlled studies on surgical approaches for excision of the submandibular gland (SMG). This study evaluated the benefits of a submental approach, compared with a conventional submandibular approach, for SMG resection. Twenty patients with benign SMG disorders, 12 with pleomorphic adenoma and eight with chronic sialadenitis with sialolithiasis, were resected using a submental (10) or submandibular (10) approach. The submental approach consisted of a horizontal incision on the submental skin and flap elevation to the gland, and the submandibular approach consisted of an incision along the skin crease overlying the SMG. Operation time, complications, hospital stay, cosmetic appearance and subjective satisfaction with the incision scar were compared between groups. The two groups were well matched in age, gender, marital status, and SMG disorders. Mean operation time, hospital stay and complication rates were comparable in the 2 groups. Mean patient satisfaction score was higher in the submental than in the submandibular group (8.8 vs. 5.4, P = .01), and the incision scar in the submental group was usually less visible. Compared with the submandibular approach, the submental approach can provide better cosmetic outcomes with no increases in operation time and complication rates.

Introduction

Excision of the submandibular gland (SMG) is usually performed using a transcervical submandibular approach. Although this surgical procedure is relatively simple, it has frequently been associated with neurologic complications after surgery, including damage to the marginal mandibular (7.7%), hypoglossal (2.9%), and lingual (1.4%) nerves.¹ In severely damaged nerves, the neurologic deficits did not resolve spontaneously. Visible scarring and symptomatic xerostomia have also been reported.2, 3

Alternative surgical approaches have been developed to avoid neurological risks and visible scarring in the upper neck. Although intraoral removal of the SMG has been reported to reduce these complications,4, 5 it has been associated with limited surgical visualization and longer operation time. Recently, to improve cosmetic results, minimally invasive endoscopic and endo-robotic methods of SMG resection through various routes have been assessed in experimental6, 7, 8, 9 and clinical studies.9, 10, 11 The operation time of endoscopic surgery, however, is significantly longer than that of conventional transcervical surgery.

In earlier reports, I described the use of a retroauricular hairline incision to remove upper neck masses, including SMG disorders.12, 13 The incision was made along the postauricular sulcus and inside the hairline, allowing the upper neck masses to be removed after subcutaneous tunneling. In prospective randomized controlled studies, the retroauricular approach provided better cosmetic outcomes, without significant complications. Subsequently, 2 additional cervical incision methods, subclavicular and submental, were developed for the removal of masses in the mid/lower and upper central neck.¹⁴ However, that study reported only six cases of SMG excision via the submental approach. I have continued to utilize the submental approach for SMG excision. In this study, I compare the submental approach for removal of the SMG with the conventional transcervical approach in a prospective, randomized controlled study.