DOCSLIB.ORG

Four-Duct Ligation a Simple and Effective Treatment for Chronic Aspiration from Sialorrhea

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Four-Duct Ligation a Simple and Effective Treatment for Chronic Aspiration from Sialorrhea ORIGINAL ARTICLE Four-Duct Ligation A Simple and Effective Treatment for Chronic Aspiration From Sialorrhea CPT Christopher Klem, MC, USA; Lt Col Eric A. Mair, USAF, MC Objectives: To determine the effectiveness of bilateral Main Outcome Measures: Incidence of postopera- submandibular and parotid duct ligation on children with tive aspiration pneumonitis; gross anatomical connec- severe neuromuscular impairment and chronic aspira- tions between the submandibular duct and sublingual tion of salivary secretions and to identify any predict- gland in cadaveric specimens. able anatomical connections between the submandibu- lar duct and sublingual glands. Results: No postoperative airway obstruction, infec- tion, or xerostomia was noted, and technetium scan- Design: Case series; retrospective anatomical study of ning confirmed control of salivary secretions from ma- adult cadaveric submandibular gland specimens. jor salivary glands. Caregivers noted diminished salivary secretions and no aspiration pneumonia. Setting: Academic tertiary referral medical center. Conclusions: This new, simple intraoral procedure con- Patients: Five children with severe neuromuscular im- trols aspiration pneumonitis with minimal surgical dis- pairment and recurrent aspiration pneumonitis. section and has less morbidity than procedures involv- ing major salivary gland excision. Ranula formation, a Intervention: The children underwent bilateral sub- common complication of submandibular duct transpo- mandibular and parotid duct ligation. The oral cavities sition, is unlikely in this procedure because the sublin- of 8 cadavers were dissected to identify anatomical con- gual ducts are not interrupted. nections between the submandibular duct and sublin- gual glands. Arch Otolaryngol Head Neck Surg. 1999;125:796-800 ROOLING IS common geries that diminish oral secretions in- among children with ce- clude transtympanic chorda tympani and rebral palsy, occurring in tympanic nerve section, submandibular an estimated 10% of gland excision, sublingual gland exci- cases.1 Children with se- sion, and parotid duct ligation or reposi- Dvere cerebral palsy may also suffer from tioning. These have all been performed recurrent life-threatening pneumonitis with various rates of success and morbid- secondary to aspiration of salivary secre- ity. Bilateral parotid duct ligation com- tions. Conservative treatment measures, bined with bilateral submandibular gland such as behavior modification to lessen excision has been shown to be as effec- drooling activity, feeding programs to tive as either laryngotracheal separation or improve oral motor function, and phar- tracheotomy in the treatment of chronic macotherapy to decrease saliva produc- aspiration, but with fewer complica- tion, are often ineffective in these tions.2 Removal of the submandibular severely affected children, and surgery glands, however, requires external inci- frequently offers the best hope for suc- sions and is associated with substantial cessful management. morbidity.3-5 Current surgical options to treat The physiological rationale behind chronic aspiration of saliva include laryn- the success of salivary duct ligation is func- From the Department of gotracheal separation and tracheotomy. tional atrophy of the affected gland. Al- Otolaryngology–Head and These are relatively aggressive proce- though this is a controversial subject, nu- Neck Surgery, Walter Reed dures that allow for improved control of merous studies have shown either Army Medical Center, aspirated secretions, but are often not ac- histological or radiographic evidence of Washington, DC. ceptable options to caregivers. Other sur- glandular atrophy as a desired result of ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 125, JULY 1999 796 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 PATIENTS AND METHODS Five patients, 1 to 17 years of age (median, 4 years), underwent surgery at the Walter Reed Army Medi- cal Center, Washington DC, between July 1, 1997, and January 31, 1998. There was a 4-year-old girl and 4 boys aged 1.2, 3, 6, and 17 years. All patients had severe cerebral palsy and recurrent pneumonitis sec- ondary to aspirated salivary secretions (average, 2.5 cases per year; range, 1 to 4 cases per year). More con- servative methods of sialorrhea control were at- tempted in all cases before surgery but were unsuc- cessful because of the severity of neuromuscular impairment. Figure 1. Preoperative view of the left parotid duct papilla. The operation was performed with the patient under general anesthesia with nasotracheal intuba- tion in 3 cases and via preexisting tracheotomy in 2 children. The oral cavity was exposed with the aid of a rubber bite block. Bilateral parotid duct ligation was performed as previously described (Figure 1, Figure 2, and Figure 3).8,9 For the second half of the operation, the distal submandibular duct papillae on either side of mid- line were identified, and 1 mL of 1% lidocaine with epinephrine 1:100 000 was injected around the site. A submucosal incision was then made between the papillae along the line of the sublingual frenulum with a No. 15 blade scalpel. A Kelly clamp was placed on the duct orifice to hold the duct while submucosal blunt dissection along the distal duct was per- formed. Care was taken not to disrupt any sublin- gual ducts that might be entering the submandibu- Figure 2. The distal right parotid duct is isolated. lar duct. When no more than 1 cm of the submandibular duct was exposed, the duct was tied in 2 places with silk sutures and the caruncle tip was cauterized on low power (Figure 4, Figure 5, and RESULTS Figure 6). The procedure was then repeated on the opposite side. The small initial incision between the Immediate mild postoperative swelling in both the sub- duct orifices was either left open or closed with an mandibular and parotid areas subsided within 2 to 3 days interrupted absorbable suture. in all children. There were no instances of aspiration pneu- A single dose of perioperative antibiotics (second- monitis, airway obstruction, fever, or wound infection generation cephalosporin) was used in all cases; how- in the immediate postoperative period, and all of the chil- ever, no patient received postoperative antibiotics or dren were able to be transferred to the pediatric ward the corticosteroids. Because of the children’s multiple day after surgery in preparation for discharge. The chil- medical problems and concern for potential airway dren did not require intravenous hydration postopera- management issues, immediate postoperative recov- ery occurred in the pediatric intensive care unit. tively because they tolerated their gastrostomy tube feeds To demonstrate the extreme anatomical varia- without difficulty. Although 3 of the children (through tion of the sublingual ducts and, thereby, help ex- the caregivers) complained of mild discomfort, this was plain the 10% rate of ranula formation encountered effectively managed with nonsteroidal analgesics and acet- in submandibular duct transposition, 16 fresh ca- aminophen. In all cases a marked decrease in the amount daveric specimens were dissected. Specifically, a pat- of drooling was noted by the caregiver before the pa- tern in the connections between the sublingual and tient was discharged. submandibular duct was sought. The period of follow-up ranged from 10 to 15 months (median, 13 months). All follow-up data are from pri- mary interviews with the patients’ caregivers and by physi- cal examination. No patient experienced an episode of duct ligation or as an unintentional consequence of duct aspiration pneumonitis since surgery. Every patient re- manipulation from various surgical procedures.6,7 Simple ported a substantial decrease in the amount of drooling intraoral ligation of the major secretory ducts of the sub- from the preoperative state; however, there were no com- mandibular and parotid glands should induce atrophy plaints of dry mouth. There were no instances of ranula of the glands and significantly decrease the production formation or swelling in the floor of the mouth. of saliva, thereby reducing the potential for aspiration of Postoperative technetium 99m albumin aggre- salivary secretions. gated (Mallinckrodt, St Louis, Mo) scan was performed ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 125, JULY 1999 797 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Figure 3. Postoperative view of the right distal parotid duct, cauterized and tied. Figure 5. The distal submandibular duct is located. Figure 4. Preoperative view of the submandibular duct papillae seen lateral Figure 6. Postoperative view of bilateral submandibular duct ligation. to the frenulum of the tongue. on 2 patients. Results showed decreased uptake in the tive measures, the success of which correlates directly with parotid and submandibular glands. The sublingual glands the degree of neuromuscular dysfunction, are often less were unaffected. effective in these severely impaired children, and sur- The results of the cadaveric dissections of the sub- gery offers the most definitive treatment. mandibular and sublingual ducts are shown in the Table. Many of the accepted surgical alternatives for treat- We found a significant and unpredictable variation be- ment of sialorrhea focus on bypassing the dysfunctional oral tween both individual specimens and opposite sides of phase of swallowing, while preserving salivary produc- the same cadaver.
Load more

Recommended publications
  • Parotid and Mandibular Salivary Glands Segmentation of the One Humped Dromedary Camel (Camelus Dromedarius)
    Int. J. Adv. Res. Biol. Sci. (2017). 4(11): 32-41 International Journal of Advanced Research in Biological Sciences ISSN: 2348-8069 www.ijarbs.com DOI: 10.22192/ijarbs Coden: IJARQG(USA) Volume 4, Issue 11 - 2017 Research Article DOI: http://dx.doi.org/10.22192/ijarbs.2017.04.11.005 Parotid and Mandibular Salivary Glands Segmentation Of The One Humped Dromedary Camel (Camelus dromedarius) Hamdy M. Rezk and Nora A. Shaker* Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Cairo University, Egypt *Corresponding author: [email protected] Abstract The present study provides detailed anatomical description of the parotid and mandibular salivary glands of the one humped camel with their segmentation based on arterial blood supply and salivary ducts; to facilitate partial removal of the pathologic gland. The shape, position, relations and blood supply of both salivary glands with their ducts were studied on six cadaveric heads. The mandibular and parotid ducts were injected with Urographin® as contrast medium; through inserting the catheter into their openings in the oral cavity; then applying lateral radiography immediately after the injection. The common carotid arteries were injected with red Latex Neoprene and dissected. The parotid gland was irregular rectangular and had five processes while the mandibular gland was irregular triangular with rounded proximal and pointed distal extremity. The parotid duct enters the oral cavity on the cheek opposite the upper 4th molar tooth. The mandibular duct opens in the oral cavity at the sublingual caruncles on the sublingual floor, just about 2cm cranial to frenulum linguae. Both The parotid and the mandibular salivary glands could be divided into four segments.
    [Show full text]
  • Head and Neck
    DEFINITION OF ANATOMIC SITES WITHIN THE HEAD AND NECK adapted from the Summary Staging Guide 1977 published by the SEER Program, and the AJCC Cancer Staging Manual Fifth Edition published by the American Joint Committee on Cancer Staging. Note: Not all sites in the lip, oral cavity, pharynx and salivary glands are listed below. All sites to which a Summary Stage scheme applies are listed at the begining of the scheme. ORAL CAVITY AND ORAL PHARYNX (in ICD-O-3 sequence) The oral cavity extends from the skin-vermilion junction of the lips to the junction of the hard and soft palate above and to the line of circumvallate papillae below. The oral pharynx (oropharynx) is that portion of the continuity of the pharynx extending from the plane of the inferior surface of the soft palate to the plane of the superior surface of the hyoid bone (or floor of the vallecula) and includes the base of tongue, inferior surface of the soft palate and the uvula, the anterior and posterior tonsillar pillars, the glossotonsillar sulci, the pharyngeal tonsils, and the lateral and posterior walls. The oral cavity and oral pharynx are divided into the following specific areas: LIPS (C00._; vermilion surface, mucosal lip, labial mucosa) upper and lower, form the upper and lower anterior wall of the oral cavity. They consist of an exposed surface of modified epider- mis beginning at the junction of the vermilion border with the skin and including only the vermilion surface or that portion of the lip that comes into contact with the opposing lip.
    [Show full text]
  • Salivary Glands
    GASTROINTESTINAL SYSTEM [Anatomy and functions of salivary gland] 1 INTRODUCTION Digestive system is made up of gastrointestinal tract (GI tract) or alimentary canal and accessory organs, which help in the process of digestion and absorption. GI tract is a tubular structure extending from the mouth up to anus, with a length of about 30 feet. GI tract is formed by two types of organs: • Primary digestive organs. • Accessory digestive organs 2 Primary Digestive Organs: Primary digestive organs are the organs where actual digestion takes place. Primary digestive organs are: Mouth Pharynx Esophagus Stomach 3 Anatomy and functions of mouth: FUNCTIONAL ANATOMY OF MOUTH: Mouth is otherwise known as oral cavity or buccal cavity. It is formed by cheeks, lips and palate. It encloses the teeth, tongue and salivary glands. Mouth opens anteriorly to the exterior through lips and posteriorly through fauces into the pharynx. Digestive juice present in the mouth is saliva, which is secreted by the salivary glands. 4 ANATOMY OF MOUTH 5 FUNCTIONS OF MOUTH: Primary function of mouth is eating and it has few other important functions also. Functions of mouth include: Ingestion of food materials. Chewing the food and mixing it with saliva. Appreciation of taste of the food. Transfer of food (bolus) to the esophagus by swallowing . Role in speech . Social functions such as smiling and other expressions. 6 SALIVARY GLANDS: The saliva is secreted by three pairs of major (larger) salivary glands and some minor (small) salivary glands. Major glands are: 1. Parotid glands 2. Submaxillary or submandibular glands 3. Sublingual glands. 7 Parotid Glands: Parotid glands are the largest of all salivary glands, situated at the side of the face just below and in front of the ear.
    [Show full text]
  • Buccal Fat Pad – a Simple, Underutilised Flap E
    SAJS Case Report Buccal fat pad – a simple, underutilised flap E. Meyer, M.B. Ch.B., F.C.O.R.L. (S.A.) S. J. R. Liebenberg, M.B. Ch.B., M.R.C.S. (Ed.), F.C.O.R.L. (S.A.) J. J. Fagan, M.B. Ch.B., M.Med., F.C.O.R.L. (S.A.) Division of Otolaryngology, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital Summary The pedicled buccal fat pad is a reliable flap for the repair of small oral defects. It is durable, easy to harvest, and should be considered in settings where access to free flaps is limited and in cases where previous flaps have failed. We discuss a case in which this flap was used successfully for closure of an oro-antral fistula. The indications, anatomy and techniques of successful harvest are discussed. S Afr J Surg 2012;50(2):47-49. A 57-year-old woman presented in 1998 with a benign minor salivary gland tumour of the hard palate. A wide local excision Fig. 2. Buccal fat pad sutured to cover the oro-antral fistula. of the tumour was performed. The excision margins extended onto the palatal bone, but no bone was excised. The greater palatine artery was ligated and the bone was left to re-epithelialise spontaneously. Two years later, she again had a benign palatal lesion which was excised. The surgery resulted in an oro-antral fistula. In 2007 she was symptomatic, with all fluids coming through her nose when drinking. A local gingival mucosal rotational flap was done without success.
    [Show full text]
  • Distribution and Roles of Substance P in Human Parotid Duct
    IJAE Vol. 121, n. 3: 219-225, 2016 ITALIAN JOURNAL OF ANATOMY AND EMBRYOLOGY Research article - Histology and cell biology Distribution and roles of substance P in human parotid duct Kaori Amano1,*, Osamu Amano2, George Matsumura3, Kazuyuki Shimada4 1,3Department of Anatomy, Kyorin University School of Medicine; 2Department of Anatomy, Meikai University School of Dentistry; 4Kagoshima University Abstract Sialadenitis occurs with greatest frequency in the parotid glands because infection and inflam- mation arise easily from the oral cavity. Since patients often experience severe swelling and pain during inflammation, the distribution of sensory nerves in these ducts may have clini- cal significance. We used antibodies to the known neuropeptide substance P and to tyrosine hydroxylase - a marker of adrenergic fibres - to observe their distribution and gain insight on their functional role in adult human parotid duct. After excising the parotid duct along with the gland, specimens were divided into three regions: the tract adjacent to the parotid gland, the route along the anterior surface of the masseter, and the area where the duct penetrates the buc- cinator muscle and opens into the oral cavity. Specimens were prepared and examined under a fluorescence microscope following immunostaining. Substance P positivity was observed in all three regions of the duct, whereas tyrosine hydroxylase was distributed mainly in the vas- cular walls and surrounding areas. The distribution of substance P candidates this molecule to assist in tissue defense in conjunction with the blood and lymph vessels of this area. Tyrosine hydroxylase in the blood vessel wall likely contributes to regulation of blood flow in concert with substance P positive nerves surrounding the blood vessels.
    [Show full text]
  • A Woman with Sore Throat and Swollen Glands
    The Journal of Emergency Medicine, Vol. 56, No. 3, pp. 340–341, 2019 Ó 2018 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter https://doi.org/10.1016/j.jemermed.2018.12.001 Visual Diagnosis in Emergency Medicine A WOMAN WITH SORE THROAT AND SWOLLEN GLANDS Paul S. Jansson, MD, MS*†‡ and Todd W. Thomsen, MD‡§ *Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, ‡Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, and §Department of Emergency Medicine, Mount Auburn Hospital, Cambridge, Massachusetts Reprint Address: Paul S. Jansson, MD, MS, Harvard Affiliated Emergency Medicine Residency, 5 Emerson Place, Suite 101, Boston, MA 02114 CASE REPORT Wharton duct of the submandibular gland, likely due to slower flow rates and a longer ductal system. The remain- A 57-year old woman presented for evaluation of swollen ing 10–20% of stones are found in the Stensen duct of the glands. She reported several days of worsening sore throat, parotid gland; sublingual stones are rare (1,2). The clinical which was accompanied by swelling to the left side of her presentation includes swelling and pain, which may be neck and jaw. She had no associated dental pain, difficulty breathing, or fevers. Her medical history was notable for deep vein thrombosis, currently on anticoagulation and remote non-Hodgkin’s lymphoma in remission. On examination, the vital signs were normal and the patient appeared uncomfortable but not systemically ill. She had no stridor and was able to tolerate her secretions. The mouth and posterior oropharynx appeared normal.
    [Show full text]
  • A Guide to Salivary Gland Disorders the Salivary Glands May Be Affected by a Wide Range of Neoplastic and Inflammatory
    MedicineToday PEER REVIEWED ARTICLE CPD 1 POINT A guide to salivary gland disorders The salivary glands may be affected by a wide range of neoplastic and inflammatory disorders. This article reviews the common salivary gland disorders encountered in general practice. RON BOVA The salivary glands include the parotid glands, examination are often adequate to recognise and MB BS, MS, FRACS submandibular glands and sublingual glands differentiate many of these conditions. A wide (Figure 1). There are also hundreds of minor sali- array of benign and malignant neoplasms may also Dr Bova is an ENT, Head and vary glands located in the mucosa of the hard and affect the salivary glands and a neoplasia should Neck Surgeon, St Vincent’s soft palate, oral cavity, lips, tongue and oro - always be considered when assessing a salivary Hospital, Sydney, NSW. pharynx. The parotid gland lies in the preauricular gland mass. region and extends inferiorly over the angle of the mandible. The parotid duct courses anteriorly Inflammatory disorders from the parotid gland and enters the mouth Acute sialadenitis through the buccal mucosa adjacent to the second Acute inflammation of the salivary glands is usu- upper molar tooth. The submandibular gland lies ally of viral or bacterial origin. Mumps is the most in the submandibular triangle and its duct passes common causative viral illness, typically affecting anteriorly along the floor of the mouth to enter the parotid glands bilaterally. Children are most adjacent to the frenulum of the tongue. The sub- often affected, with peak incidence occurring at lingual glands are small glands that lie just beneath approximately 4 to 6 years of age.
    [Show full text]
  • Marsupialisation of Bilateral Ranula in a Buffalo Calf
    MOJ Anatomy & Physiology Research Article Open Access Marsupialisation of bilateral ranula in a buffalo calf Abstract Volume 8 Issue 1 - 2021 Diabetes in elderly patients has frequent occurrence of geriatric syndrome. It includes a Kalaiselvan E, Swapan Kumar Maiti, Azam Ranula refers to accumulation of extra-glandular saliva in the floor of the mouth interfering the normal feeding. A male buffalo calf, age of 6 months had bilateral sublingual sialocele Khan, Naveen Kumar Verma, Mohar Singh, (ranula) showing difficulty to masticate and drink water. Bilateral ranula was excised Sharun Khan, Naveen Kumar elliptically to facilitate dynamic fluid/saliva drainage and marsupialisation performed under Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India anesthesia. Animal showed uneventful recovery without any postoperative complications. Correspondence: Swapan Kumar Maiti, Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India, Email Received: January 15, 2021 | Published: Febrauary 15, 2021 Introduction saliva into the mouth (Figure 1–4). The owner was advised to clean the oral cavity with povidone iodine for 7 days. Postoperatively, Ranula or sublingual sialocele refers to a collection of extra- antibiotic, analgesic and fluid therapy was administered for 5 days. glandular and extra-ductal saliva in the floor of the mouth originating On 10thpost-operative day animal showed normal feeding habit and from the sublingual salivary gland. It
    [Show full text]
  • Head and Neck Contouring
    Practical Medical Physics: Head and Neck Contouring AAPM 2011 Vancouver, British Columbia Jonn Wu, BMSc MD FRCPC Radiation Oncologist, Vancouver Cancer Centre, BCCA Clinical Assistant Professor, UBC August 2nd, 2011 Objectives Review Selection of Normal Organs • Brachial Plexus • Pharyngeal Constrictors • Salivary Glands • Parotid • Submandibular Target Audience: • Physicists • Dosimetrists • Radiation Therapists Outline Why do we have to Contour? Which Organs are Important? How *I* contour? 3 Important Organ Systems • Xerostomia: Salivary Glands • Parotid • Submandibular • Dysphagia: Pharyngeal Constrictors • Brachial Plexus Outline (cont) For Each Organ System • Anatomy • Literature • Examples Why do we have to contour? • Target delineation • Organ avoidance 2D → 3D → IMRT (your fault) 2D Planning 2D Planning 2.5D… 3DCRT IMRT IMRT & Contours • Inverse Planning • Objective Cost Function • Computers are Binary Why take a contouring course? • IMRT and 3D = standard practice • Both techniques require (accurate) contours • Clinical trials require dose constraints • Consistency (precision) • Who: • Intra- vs inter-contourer • Intra- vs inter-institutional • Why: • Good practice • Dose constraints • Dosimetric repositories Why take a contouring course? • No formal training • Few reproducible guidelines • Everyone assumes consistent contouring • NCIC HN6, RTOG 0920, 0615, 0225 • Spinal Cord: • Intra-observer: avg 0.1 cm, max 0.7 cm • Inter-observer: avg 0.2 cm, max 0.9 cm Geets RO 2005 Which organs are important Brain (temporal lobe) Globe,
    [Show full text]
  • Congenital Bilateral Ectopic Parotid Glands: Case Report and Systematic Review of the Literatures
    1170 Case Report Congenital bilateral ectopic parotid glands: case report and systematic review of the literatures Shang Xie#, Zi-Meng Li#, Shi-Jun Li, Zhi-Gang Cai Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing, China #These authors contributed equally to this work. Correspondence to: Zhi-Gang Cai. Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22# Zhongguancun South Avenue, Haidian District, Beijing 100081, China. Email: [email protected]. Abstract: Cheek swelling can be attributed to several pathologies, including masseteric hypertrophy, diffuse inflammatory changes and neoplasia. We report an extremely rare case of bilateral cheek swelling as a result of ectopic parotid glands. This case is a young female patient with bilateral ectopic parotid glands superficial to the masseter muscle and the zygomatic arch, demonstrated by the enhanced computed tomography (CT). Medical history, clinical features, videography and management of this case are described. After two years of observation, no significant change in symptoms was observed on this patient. Besides, we conducted a case report and systematic review of cases of ectopic parotid gland. A literature search was performed using PubMed, Web of Science, and Ovid electronic database. A total of 144 papers were retrieved and only one paper was included in the systematic review. In conclusion, bilateral ectopic parotid gland is extremely rare and easily confused with other lumps in the area of head and neck.
    [Show full text]
  • Submandibular Gland Excision
    OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY SUBMANDIBULAR SALIVARY GLAND EXCISION Johan Fagan The submandibular salivary gland (SMG) The digastric muscle forms the anteroinfe- may be excised for chronic sialadenitis, rior and posteroinferior boundaries of the sialectasis, sialolithiasis, benign and malig- submandibular triangle (Figure 2). It is an nant tumours, and as part of a neck dissect- important surgical landmark as there are no tion. The use of sialendoscopy is likely to important structures lateral to the muscle. reduce the frequency of SMG excision for The facial artery emerges from immediate- sialolithiasis. ly medial to the posterior belly, and the XIIn runs immediately deep to the digas- The key concerns for the patient are the tric tendon. surgical scar, and injury to the marginal mandibular, lingual and hypoglossal ner- The mylohyoid muscle is a flat muscle at- ves. tached 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 com- are no important vascular or neurological ponents of the gland. The SMG is situated structures superficial to the mylohyoid; the mainly in the submandibular triangle lingual and XIIn are both deep to the (Level 1b) of the neck.
    [Show full text]
  • Parotid Gland  It Is the Largest Salivary Gland (Serous)
    Anatomy& innervations of parotid,Submandibular &Sublingual Glands parotid gland It is the largest salivary gland (serous). It is located in a deep space behind ramus of mandible & in front of sternocleidomastoid. It is wedge shaped , with its base (concave upper end) lies above and related to cartilaginous part of external acoustic meatus/ and its apex (lower end) lies below & behind angle of mandible. It has 2 borders : anterior convex border + straight posterior border. Facial N. passes within the gland and divides it into superficial & deep parts or lobes. Processes of the parotid gland : It has 4 processes. Superior margin of the gland extends upward behind temporo- mandibular joint into mandibular fossa of skull ….. Glenoid process. Anterior margin of the gland extends forward superficial to masseter … facial process. A small part of facial process may be separate from main gland… accessory part of gland, that lies superficial to masseter. Deep part of gland may extend between medial pterygoid & ramus of mandible … pterygoid process. Capsules of the Gland & Parotid Duct : It is surrounded by 2 capsules, the first is C.T. capsule, the second is the dense fascial capsule of investing layer of deep cervical fascia, (part of it is thickened to form stylomandibular ligament). Parotid duct 5 cm.long, passes from anterior border of gland , superficial to masseter one fingerbreadth, below zygomatic arch, then it pierces buccal pad of fat & buccinator muscle. It passes obliquley between buccinator & m.m.of mouth (serves as valvelike mechanism to prevent inflation of duct during violent blowing) and finally opens into vestibule of mouth ,opposite upper 2nd molar tooth • Structures within the parotid gland From lateral to medial (horizontal section) : 1-Facial N.---- emerges from stylomastoid foramen to enter the gland at its posteromedial surface, and divides into 5 terminal branches.
    [Show full text]