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Surgical bypass of submandibular duct stricture
Surgical bypass of submandibular duct stricture Louis Mandel, DDS,a and Ayfer Kaynar, DDS,b New York, NY, and Istanbul, Turkey COLUMBIA UNIVERSITY, NEW YORK PRESBYTERIAN HOSPITAL, AND UNIVERSITY OF ISTANBUL
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:532-3)
Stricturing of the submandibular duct will cause obstructive glandular symptoms. Such strictures are often the sequel to surgery involving the duct’s orifice in the anterior mouth floor.1,2 Wound healing with its consequent scarring leads to this not unexpected result. The obstructive stricture causes repeated episodes of gland swelling and pain, usually evident at mealtime. Inevitably, gland pathosis develops from the chronic obstruction while the associated salivary stagnation favors bacterial invasion. Bacterial sialadenitis and glandular degenerative changes can be anticipated. To prevent the gland’s downward spiral, intervention is mandated. We report a surgical procedure whose purpose is to abort the obstructive symptoms resulting from stricturing in the anterior segment of the submandibular duct. The location of the stricture at the most anterior (distal) portion of the duct offers an opportunity to make a new opening, posteriorly (proximally) placed. The area of obstruction can thus be bypassed.
SURGERY An anteroposterior linear incision, 1.5 cm in length, is made in the mucosa of the cuspid-bicuspid area of the mouth floor. The incision is made parallel and just lateral to the height of the plica sublingualis (sublingual fold). By means of blunt dissection, the body of Wharton’s duct can be visualized through the surgically developed mucosal window (Fig 1, A). The duct is readily freed from its soft tissue bed and isolated with 1⁄4-inch umbilical tape, which is used to circumscribe the duct in the cuspid area. With gentle tension, the tape is used to retract the encompassed duct in an anterior and superior direction. Because of the tension, it is possible to make a 1-cm longitudinal incision into the superior wall of the duct aDirector, Salivary Gland Center; Clinical Professor, Division of Oral and Maxillofacial Surgery, Columbia University School of Dental and Oral Surgery and New York Presbyterian Hospital. bAssociate Professor, Division of Oral and Maxillofacial Surgery, School of Dentistry, University of Istanbul, Turkey. Received for publication Apr 13, 1999; returned for revision Apr 13, 1999; accepted for publication May 25, 1999. Copyright © 1999 by Mosby, Inc. 1079-2104/99/$8.00 + 0 7/12/100553
532
(Fig 1, B). The longitudinal incision results in a filleted duct whose wings are sutured (with 5-0 chromic) to the adjacent mouth floor mucosa (Fig 1, C). The umbilical tape, which was positioned around the duct in the region corresponding to the cuspid area, is removed and replaced by a 3-0 silk suture. This suture is used to ligate the duct immediately anterior to the sutured wings of the filleted duct. With the duct ligated, the untouched anterior duct segment is retracted by grasping the silk suture. This anterior segment is surgically sectioned at a point between the retracting suture and the filleted duct. Once transected, the anterior duct segment is surgically dissected free to the orifice area. Excision of this anterior segment and its contiguous orifice and surrounding caruncula are completed and followed by suturing (with 3-0 silk) of the mucosa of the mouth floor. A primary closure can readily be obtained. A new patent duct orifice is now present where the filleted duct wings had been sutured in the mouth floor bicuspidmolar area. Healing progresses rapidly. Within 1 week, a healed new opening with saliva exiting from the surgically created orifice can be seen.
DISCUSSION Anatomically, the depth of the 5-cm long Wharton’s duct in the mouth floor decreases as it moves anteriorly to its orifice. Because anteriorly it is relatively superficially placed and because of its forward position, the duct becomes readily accessible to the surgeon. Posteriorly, visibility is poor and accessibility is physically compromised. Therefore, surgical duct bypasses are feasible only if the obstruction is situated forward enough that a new orifice can be constructed posteriorly. It becomes surgically difficult, if not impossible, to develop an orifice posterior to the plane of the mandibular first molar. The removal of an obstruction in the form of a stone in the more anterior regions of the duct, as described by Seward,3 was also followed by suturing a filleted duct to the mouth floor. However, the anterior segment with its connection to the orifice was retained. This retention allows for the existence of a ductal blind sac with an opening on the caruncula. Such a non–self-
Mandel and Kaynar 533
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 88, Number 5
cleansing anatomical pocket harbors those conditions that favor infection. Furthermore, the inevitable stagnation associated with the occasional presence of sublingual gland secretions from connecting sublingual gland ducts predisposes to stone formation.4 Because sublingual salivary gland ducts can empty into the anterior segment of Wharton’s duct,4 excising this segment of Wharton’s duct can disrupt the continuity of these sublingual ducts. Ranula is a possible complication, and it has been reported as an infrequent complication after redirection of the submandibular duct for the treatment of drooling.5 The use of a cannula in the development of a new duct orifice has not met with great success. The mouth floor is in constant motion because it takes part in speech, mastication, and deglutition. A rigid or semirigid stent tethered to the surrounding soft tissue cannot move in harmony with the mobile mouth floor during function; consequently, displacement occurs.2,6 Anchoring with sutures will temporarily act to restrain a catheter, but the tension created with oral movement inevitably causes the sutures to dissect through the attached tissue margins. The process of stent expulsion, superimposed on the original surgical inflammation, incites a traumatic inflammation and results in an additional increase in postoperative scarring.6 Furthermore, healing with collagen formation occurs over a 3-month period; afterward, the collagen undergoes a structural fiber modification, with even further contracture.7 Because the cannula itself may add to the scarring and because retention cannot be successfully maintained for the requisite time to overcome scarring, its use should be avoided.
A
B
C Fig 1. A, Wharton’s duct visualized through mucosal incision made in anterior mouth floor. B, Incision in mouth floor shows duct retracted by umbilical tape in anterior and superior direction. Longitudinal incision made into superior wall of duct. Anterior (distal) duct segment, caruncula, and duct orifice are outlined. C, Filleted duct wall sutured to mucosa of mouth floor. Ligature is placed around anterior duct segment.
REFERENCES 1. Stimson CW, Leban SG. Transplantation of the submandibular duct associated with resection for carcinoma. Oral Surg Oral Med Oral Pathol 1983;56:136-40. 2. Ord RA, Lee VE. Submandibular duct repositioning after excision of floor of mouth cancer. J Oral Maxillofac Surg 1996;54:1074-8. 3. Seward GR. Anatomic surgery for salivary calculi, vii: complications of salivary calculi. Oral Surg Oral Med Oral Pathol 1963:26:137-44. 4. Patton DW. Recurrent calculus formation following removal of the submandibular salivary gland. Br J Oral Maxillofac Surg 1987;25:15-20. 5. Crysdale WS, White A. Submandibular duct relocation for drooling: a 10-year experience with 194 patients. Otolaryngol Head Neck Surg 1989;101:87-92.
6. Mandel L. Discussion. Submandibular duct repositioning after excision of floor of mouth cancer [discussion]. J Oral Maxillofac Surg 1996;54:1078-9. 7. Cotran RS, Kumar V, Robbin SL. Pathologic basis of disease. 5th ed. Philadelphia: Saunders; 1994. p. 86-9.
Reprint requests: Louis Mandel, DDS Columbia University School of Dental and Oral Surgery 630 West 168th Street New York, NY 10032
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:532-3)
Stricturing of the submandibular duct will cause obstructive glandular symptoms. Such strictures are often the sequel to surgery involving the duct’s orifice in the anterior mouth floor.1,2 Wound healing with its consequent scarring leads to this not unexpected result. The obstructive stricture causes repeated episodes of gland swelling and pain, usually evident at mealtime. Inevitably, gland pathosis develops from the chronic obstruction while the associated salivary stagnation favors bacterial invasion. Bacterial sialadenitis and glandular degenerative changes can be anticipated. To prevent the gland’s downward spiral, intervention is mandated. We report a surgical procedure whose purpose is to abort the obstructive symptoms resulting from stricturing in the anterior segment of the submandibular duct. The location of the stricture at the most anterior (distal) portion of the duct offers an opportunity to make a new opening, posteriorly (proximally) placed. The area of obstruction can thus be bypassed.
SURGERY An anteroposterior linear incision, 1.5 cm in length, is made in the mucosa of the cuspid-bicuspid area of the mouth floor. The incision is made parallel and just lateral to the height of the plica sublingualis (sublingual fold). By means of blunt dissection, the body of Wharton’s duct can be visualized through the surgically developed mucosal window (Fig 1, A). The duct is readily freed from its soft tissue bed and isolated with 1⁄4-inch umbilical tape, which is used to circumscribe the duct in the cuspid area. With gentle tension, the tape is used to retract the encompassed duct in an anterior and superior direction. Because of the tension, it is possible to make a 1-cm longitudinal incision into the superior wall of the duct aDirector, Salivary Gland Center; Clinical Professor, Division of Oral and Maxillofacial Surgery, Columbia University School of Dental and Oral Surgery and New York Presbyterian Hospital. bAssociate Professor, Division of Oral and Maxillofacial Surgery, School of Dentistry, University of Istanbul, Turkey. Received for publication Apr 13, 1999; returned for revision Apr 13, 1999; accepted for publication May 25, 1999. Copyright © 1999 by Mosby, Inc. 1079-2104/99/$8.00 + 0 7/12/100553
532
(Fig 1, B). The longitudinal incision results in a filleted duct whose wings are sutured (with 5-0 chromic) to the adjacent mouth floor mucosa (Fig 1, C). The umbilical tape, which was positioned around the duct in the region corresponding to the cuspid area, is removed and replaced by a 3-0 silk suture. This suture is used to ligate the duct immediately anterior to the sutured wings of the filleted duct. With the duct ligated, the untouched anterior duct segment is retracted by grasping the silk suture. This anterior segment is surgically sectioned at a point between the retracting suture and the filleted duct. Once transected, the anterior duct segment is surgically dissected free to the orifice area. Excision of this anterior segment and its contiguous orifice and surrounding caruncula are completed and followed by suturing (with 3-0 silk) of the mucosa of the mouth floor. A primary closure can readily be obtained. A new patent duct orifice is now present where the filleted duct wings had been sutured in the mouth floor bicuspidmolar area. Healing progresses rapidly. Within 1 week, a healed new opening with saliva exiting from the surgically created orifice can be seen.
DISCUSSION Anatomically, the depth of the 5-cm long Wharton’s duct in the mouth floor decreases as it moves anteriorly to its orifice. Because anteriorly it is relatively superficially placed and because of its forward position, the duct becomes readily accessible to the surgeon. Posteriorly, visibility is poor and accessibility is physically compromised. Therefore, surgical duct bypasses are feasible only if the obstruction is situated forward enough that a new orifice can be constructed posteriorly. It becomes surgically difficult, if not impossible, to develop an orifice posterior to the plane of the mandibular first molar. The removal of an obstruction in the form of a stone in the more anterior regions of the duct, as described by Seward,3 was also followed by suturing a filleted duct to the mouth floor. However, the anterior segment with its connection to the orifice was retained. This retention allows for the existence of a ductal blind sac with an opening on the caruncula. Such a non–self-
Mandel and Kaynar 533
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 88, Number 5
cleansing anatomical pocket harbors those conditions that favor infection. Furthermore, the inevitable stagnation associated with the occasional presence of sublingual gland secretions from connecting sublingual gland ducts predisposes to stone formation.4 Because sublingual salivary gland ducts can empty into the anterior segment of Wharton’s duct,4 excising this segment of Wharton’s duct can disrupt the continuity of these sublingual ducts. Ranula is a possible complication, and it has been reported as an infrequent complication after redirection of the submandibular duct for the treatment of drooling.5 The use of a cannula in the development of a new duct orifice has not met with great success. The mouth floor is in constant motion because it takes part in speech, mastication, and deglutition. A rigid or semirigid stent tethered to the surrounding soft tissue cannot move in harmony with the mobile mouth floor during function; consequently, displacement occurs.2,6 Anchoring with sutures will temporarily act to restrain a catheter, but the tension created with oral movement inevitably causes the sutures to dissect through the attached tissue margins. The process of stent expulsion, superimposed on the original surgical inflammation, incites a traumatic inflammation and results in an additional increase in postoperative scarring.6 Furthermore, healing with collagen formation occurs over a 3-month period; afterward, the collagen undergoes a structural fiber modification, with even further contracture.7 Because the cannula itself may add to the scarring and because retention cannot be successfully maintained for the requisite time to overcome scarring, its use should be avoided.
A
B
C Fig 1. A, Wharton’s duct visualized through mucosal incision made in anterior mouth floor. B, Incision in mouth floor shows duct retracted by umbilical tape in anterior and superior direction. Longitudinal incision made into superior wall of duct. Anterior (distal) duct segment, caruncula, and duct orifice are outlined. C, Filleted duct wall sutured to mucosa of mouth floor. Ligature is placed around anterior duct segment.
REFERENCES 1. Stimson CW, Leban SG. Transplantation of the submandibular duct associated with resection for carcinoma. Oral Surg Oral Med Oral Pathol 1983;56:136-40. 2. Ord RA, Lee VE. Submandibular duct repositioning after excision of floor of mouth cancer. J Oral Maxillofac Surg 1996;54:1074-8. 3. Seward GR. Anatomic surgery for salivary calculi, vii: complications of salivary calculi. Oral Surg Oral Med Oral Pathol 1963:26:137-44. 4. Patton DW. Recurrent calculus formation following removal of the submandibular salivary gland. Br J Oral Maxillofac Surg 1987;25:15-20. 5. Crysdale WS, White A. Submandibular duct relocation for drooling: a 10-year experience with 194 patients. Otolaryngol Head Neck Surg 1989;101:87-92.
6. Mandel L. Discussion. Submandibular duct repositioning after excision of floor of mouth cancer [discussion]. J Oral Maxillofac Surg 1996;54:1078-9. 7. Cotran RS, Kumar V, Robbin SL. Pathologic basis of disease. 5th ed. Philadelphia: Saunders; 1994. p. 86-9.
Reprint requests: Louis Mandel, DDS Columbia University School of Dental and Oral Surgery 630 West 168th Street New York, NY 10032