Sublingual Gland Excision and Ductal Surgery

Armamentarium

  • #11 and #15 Scalpel blades

  • Allis clamp

  • Appropriate sutures

  • Bipolar electrocautery

  • Bite block or Molt mouth prop

  • Blunt tenotomy scissors

  • Bowman lacrimal probes

  • DeBakey forceps

  • Gerald serrated and toothed forceps

  • Headlight

  • Kelly hemostats (curved and straight)

  • Local anesthetic with vasoconstrictor

  • Loupe magnification (2.5×)

  • Mayo scissors

  • Mosquito hemostats

  • Needle electrocautery

  • Schnidt right-angle tonsil forceps (Sawtell or Mixter)

  • Schnidt tonsil forceps (Boettcher)

  • Single skin hook

  • Skin staples (used if a cervical incision is made)

  • Surgical peanut sponges or Kittner sponges

  • Weider tongue retractor

History of the Procedure

It is difficult to find in the literature a report of the very first sublingual gland excision; however, early descriptions of the procedure can be found that are mainly related to the treatment of oral and plunging ranulas. Therefore, it is necessary to discuss the etiology, pathogenesis, and treatment of oral and plunging ranulas. Ranulas have been described for centuries, but there has always been controversy over their etiology. Hippocrates and Celsius believed that they were inflammatory in origin. In 1585, Banister wrote that “ranula is a tumor in that laxe and saufte parte of the mouth, which is under the tongue.” He tried to cure ranulas first with the application of medicaments, and if that was unsuccessful, he opened them with cautery and applied the medicaments to the opened cavity. In 1676, Wiseman observed that ranulas caused a croaking speech, and he described the oral ranula’s blue-domed, cystic appearance as resembling the bulging underbelly or air sac of a frog—hence the term ranula ( rana is the Latin word for frog) ( Figure 86-1, A ). Early theories about the origin of the ranula included the existence of a submucosal bursa, possibly branchial in origin or possibly originating from remnants of the external paralingual groove or from remnants of the thyroglossal duct and chronic myxangitis of a salivary gland or chronic inflammation ( Figure 86-1, B E ). It was not until 1887 that Suzanne, followed by von Hipple in 1897, associated the sublingual gland with the origin of the ranula and recommended removal of the sublingual gland and ranula. In 1957, Crile performed sublingual gland excisions for recurrent plunging ranulas after attempts to remove the plunging ranulas through a cervical approach without removal of the sublingual gland and after removal of the submandibular gland failed. He concluded that excision of the ranula without removal of the sublingual gland resulted in recurrence. In 1965, Cohen and Tiecke equated ranulas pathologically with mucoceles of minor salivary glands and, as for mucoceles, recommended excision of the lesion and the associated gland, the sublingual gland. In 1969, Catone et al. published nine cases of nonplunging ranulas successfully treated with excision of the sublingual gland and proposed that the sublingual gland and its excretory system were the origin of the ranula. In 1973, Roediger et al. confirmed that the sublingual gland was the source of plunging ranulas by comparing the fluid contained within the plunging ranulas to the secretions of the different major salivary glands. They found that the cyst fluid and sublingual gland secretions had a higher amylase content than that of serum but a lower amylase and higher protein content than that of the submandibular and parotid glands because of its more mucinous than serous production.

Figure 86-1
A, Photograph of a recurrent oral ranula in a 5-year-old female initially treated with marsupialization. She was subsequently treated with sublingual gland excision. B and C, Histologic sections of the patient’s sublingual gland show a mild, patchy, chronic inflammatory infiltrate of lymphocytes. The sublingual gland also shows either no capsule or an incomplete capsule compared to the other major salivary glands; no capsule is observed in these sections. D and E, Histologic sections of the plunging ranula seen in the patient show a large pseudocyst with a thin, fibrous wall. Mucous contents are present. The pseudocyst wall varies from a dense fibrous layer with no evident epithelial lining to a more inflamed and congested wall with possible residual mucous epithelium. Some areas show intramural macrophages with probable mucinous contents.

It is currently believed that there are two varieties of ranulas. The less common variety is the result of a mucus retention phenomenon; the other variety is the result of mucous extravasation or the mucous escape phenomenon. In 1685, Diemerbrock theorized that ranulas resulted from obstruction and retention of saliva in the excretory duct of a salivary gland. This theory, that ranulas developed after complete or partial obstruction of an excretory duct and therefore led to ductal dilation and the eventual formation of an epithelial-lined retention cyst, persisted for many years. However, in 1956 Bhaskur et al. reviewed 19 of their surgical specimens of ranulas and found that they were lined only by connective tissue. In 1959, Standish and Shafer reviewed 97 cases of ranulas. They found that in 91 cases, the lesions were composed of a dense connective tissue capsule and that only six contained a partial or complete epithelial lining. In 1964, Robinson and Hjorting-Hansen reviewed 125 ranulas and found that only 22 contained a partial or complete epithelial lining. Crile and others were also able to show that mucous extravasation and pseudocyst formation were the etiology of plunging ranulas ( Figures 86-2 and 86-3 ).

Figure 86-2
Frontal section through the tongue and sublingual and submandibular regions.

Figure 86-3
Submandibular and sublingual glands. Note the following: (1) With the tongue removed and the genioglossus and geniohyoid muscles cut, the submandibular and sublingual glands are exposed and their relationship to the inner aspect of the mandible is shown; (2) the submandibular duct measures about 5 cm and courses anteriorly between the sublingual gland and genioglossus muscle (cut). It opens in the floor of the mouth at the sublingular caruncle.

History of the Procedure

It is difficult to find in the literature a report of the very first sublingual gland excision; however, early descriptions of the procedure can be found that are mainly related to the treatment of oral and plunging ranulas. Therefore, it is necessary to discuss the etiology, pathogenesis, and treatment of oral and plunging ranulas. Ranulas have been described for centuries, but there has always been controversy over their etiology. Hippocrates and Celsius believed that they were inflammatory in origin. In 1585, Banister wrote that “ranula is a tumor in that laxe and saufte parte of the mouth, which is under the tongue.” He tried to cure ranulas first with the application of medicaments, and if that was unsuccessful, he opened them with cautery and applied the medicaments to the opened cavity. In 1676, Wiseman observed that ranulas caused a croaking speech, and he described the oral ranula’s blue-domed, cystic appearance as resembling the bulging underbelly or air sac of a frog—hence the term ranula ( rana is the Latin word for frog) ( Figure 86-1, A ). Early theories about the origin of the ranula included the existence of a submucosal bursa, possibly branchial in origin or possibly originating from remnants of the external paralingual groove or from remnants of the thyroglossal duct and chronic myxangitis of a salivary gland or chronic inflammation ( Figure 86-1, B E ). It was not until 1887 that Suzanne, followed by von Hipple in 1897, associated the sublingual gland with the origin of the ranula and recommended removal of the sublingual gland and ranula. In 1957, Crile performed sublingual gland excisions for recurrent plunging ranulas after attempts to remove the plunging ranulas through a cervical approach without removal of the sublingual gland and after removal of the submandibular gland failed. He concluded that excision of the ranula without removal of the sublingual gland resulted in recurrence. In 1965, Cohen and Tiecke equated ranulas pathologically with mucoceles of minor salivary glands and, as for mucoceles, recommended excision of the lesion and the associated gland, the sublingual gland. In 1969, Catone et al. published nine cases of nonplunging ranulas successfully treated with excision of the sublingual gland and proposed that the sublingual gland and its excretory system were the origin of the ranula. In 1973, Roediger et al. confirmed that the sublingual gland was the source of plunging ranulas by comparing the fluid contained within the plunging ranulas to the secretions of the different major salivary glands. They found that the cyst fluid and sublingual gland secretions had a higher amylase content than that of serum but a lower amylase and higher protein content than that of the submandibular and parotid glands because of its more mucinous than serous production.

Figure 86-1
A, Photograph of a recurrent oral ranula in a 5-year-old female initially treated with marsupialization. She was subsequently treated with sublingual gland excision. B and C, Histologic sections of the patient’s sublingual gland show a mild, patchy, chronic inflammatory infiltrate of lymphocytes. The sublingual gland also shows either no capsule or an incomplete capsule compared to the other major salivary glands; no capsule is observed in these sections. D and E, Histologic sections of the plunging ranula seen in the patient show a large pseudocyst with a thin, fibrous wall. Mucous contents are present. The pseudocyst wall varies from a dense fibrous layer with no evident epithelial lining to a more inflamed and congested wall with possible residual mucous epithelium. Some areas show intramural macrophages with probable mucinous contents.

It is currently believed that there are two varieties of ranulas. The less common variety is the result of a mucus retention phenomenon; the other variety is the result of mucous extravasation or the mucous escape phenomenon. In 1685, Diemerbrock theorized that ranulas resulted from obstruction and retention of saliva in the excretory duct of a salivary gland. This theory, that ranulas developed after complete or partial obstruction of an excretory duct and therefore led to ductal dilation and the eventual formation of an epithelial-lined retention cyst, persisted for many years. However, in 1956 Bhaskur et al. reviewed 19 of their surgical specimens of ranulas and found that they were lined only by connective tissue. In 1959, Standish and Shafer reviewed 97 cases of ranulas. They found that in 91 cases, the lesions were composed of a dense connective tissue capsule and that only six contained a partial or complete epithelial lining. In 1964, Robinson and Hjorting-Hansen reviewed 125 ranulas and found that only 22 contained a partial or complete epithelial lining. Crile and others were also able to show that mucous extravasation and pseudocyst formation were the etiology of plunging ranulas ( Figures 86-2 and 86-3 ).

Figure 86-2
Frontal section through the tongue and sublingual and submandibular regions.

Figure 86-3
Submandibular and sublingual glands. Note the following: (1) With the tongue removed and the genioglossus and geniohyoid muscles cut, the submandibular and sublingual glands are exposed and their relationship to the inner aspect of the mandible is shown; (2) the submandibular duct measures about 5 cm and courses anteriorly between the sublingual gland and genioglossus muscle (cut). It opens in the floor of the mouth at the sublingular caruncle.

Indications for the Use of the Procedure

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Sublingual Gland Excision and Ductal Surgery
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