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The submandibular salivary gland in radical neck dissection specimens
The Submandibular Salivary Gland in Radical Neck Dissection Specimens CHARLES J. STALEY,M.D., HARRY A. KAUPP,JR., M.D.ANDECKHARDFISCHER, From tbe Departments of Surgery, Veterans Administration Research Hospital and Nortbwestern University Medical School, Chicago, Illinois.
Chicago, Illinois
representing the experiences of a singIe surgical service, have been restudied. These dissections were performed unilaterahy or bilateraIIy, alone or incontinuity with Iaryngectomy or remova of an intraora1 tumor. The incidence of the various pathoIogic alterations is not significant because it is reIated to the frequency of obstruction of the duct or prior radiotherapy which vary with the nature, Iocation and treatment of the primary tumor. Two to eight sections of each gland, stained with hematoxylin and eosin, were studied. Since this study consisted for the most part of a re-evaIuation of tissues aIready prepared and mounted it is recognized that study of step sections or seria1 sections of aI1 gIands might have produced somewhat different results. The sequeIa of obstruction or radiotherapy generahy invoIve the gland diffuseIy and couId hardIy escape detection, but a small intraglandular node or metastasis could have been missed. Nevertheless, in the latter portion of the study, a more thorough pathoIogic evaluation was accomplished without inff uencing the resuIt.
SUBMANDIBULAR Sahary gIand is removed in a11 cervical Iymph node dissections but is rarely subjected to carefuI histologic evaluation. PathoIogic examination of the surgica1 specimen usuaIIy results in a brief notation that the gIand is normal, or at most, free of metastatic disease. ActualIy, abnormalities occasionahy are observed which are of chnical significance. In order to evaIuate these pathoIogic aIterations the microscopic sections from 150 neck dissections have been reviewed. Our interest was stimuIated initiahy by the process we refer to as scIerosing siaIadenitis, a sequel of irradiation of the submandibuIar salivary gIand or obstruction of its duct. The Iatter may be secondary to invasion by tumor or to operative intervention in which continuity of the duct is interrupted, but the gIand‘is not removed. Regardless of the mechanism of production, the resultant mass is readiIy paIpable beneath the body of the mandibIe and has been interpreted erroneousIy as a Iymph node metastasis. As the study progressed, we deveIoped considerable interest in the Iymphatic reIationships of the submandibular gland. Being famihar with the concept that a lymph node is contained within the substance of the gland, we were impressed by its absence and by the absence of intraglandular metastases, noda or otherwise. It appears that the anatomic reIationship of the submandiburar sahvary gland to the Iymphatic system of the upper cervica1 region is not we11 understood.
T
M.D.,
HE
SCLEROSING
SIALADENITIS
The majority of the submandibuIar gIands were considered normaI, aIthough minor degrees of inflammatory infiltrate or minima1 fibrosis were occasionahy present. With few exceptions the normaI glands were removed from patients who had not received radiotherapy, and whose tumors were not anatomically related to the gland or its duct. It is again pertinent to note that lymph nodes, one or several, subcapsular or intragIanduIar, were not found in any of these specimens. Varying degrees of scIerosing siaIadenitis were found in the obstructed submandibuIar gIands. Microscopically, fibrous repIacement of
MATERIAL The microscopic sections of the submandibuIar sahvary gIands from 150 neck dissections, 831
American
Journal
J Surgery,
Volume: rd.
November
1963
StaIey,
Kaupp
acinar tissue was the ruIe, but the integrity of the remaining acini was preserved. Fibrosis was often extreme. It was predominantIy periIobuIar. The ducts escaped destruction and appeared unduIy prominent; some were dilated and contained mucin producing cells. An inflammatory infiltrate, predominantly Iymphocytic but also containing plasma cells, was almost invariably present. ClinicaIIy apparent sclerosing siaIadenitis is associated most often with tumors arising in or secondariIy invading the anterior portion of the floor of the mouth. This rerationship was noted as Iong ago as rg4o by Martin and Sugarbaker [I]; Evans and Ackerman [2] have recently called attention to the process. We have noted invoIvement of the contralateral gland when remova of a uniIatera1 tumor required an intraora1 incision extending beyond the midIine. Such a resection incIudes the termina1 portion of the contraIatera1 duct which is subsequentIy occIuded in the reconstruction of the mouth. Obstruction, so produced, ordinariIy is not foIIowed by cIinica1 infection. Rather, the gland undergoes progressive fibrosis and parenchyma1 atrophy with the production of a firm, nontender mass which may be mistaken for a metastasis to a submandibuIar lymph node. Sclerosing submandibuIar sialadenitis secondary to irradiation was found most commonIy in patients with tumors arising from the ora mucosa. SeveraI patients, who previousIy received irradiation because of tumors of the Iarynx or pharynx, were found to have similar though generaIIy Iess severe aIterations. The cIinica1 pattern is essentiaIIy the same as that which foI1ows obstruction of a duct. HistoIogicaIIy, the acinar structures showed varying degrees of disruption. CeIIuIar detaiI was poorIy preserved, and in severe cases remaining acinar tissues often appeared as blurred, muItinucIeated cytopIasmic masses. The nucIei were often Iarge and pleomorphic but not hyperchromatic. The ducta epitheIium was Iess affected. IntraIobuIar fibrosis was often prominent. VascuIar changes compatible with the effect of irradiation were frequentIy seen. A more detaiIed study of the histoIogic changes in obstructed and irradiated submandibuIar sabvary gIands, utiIizing additiona staining technics, is in progress.
and Fischer LYMPHATIC SUBMANDIBULAR
RELATIONSHIPS SALIVARY
OF GLAND
In this entire study neither a subcapsular nor an intragIanduIar lymph node was observed. Nor were metastases found in any of these submandibular gIands. (Positive nodes were present in 80 per cent of the specimens.) Tumor had invaded the gIand by direct extension in one instance, and was found in the tissues and nodes adjacent to the gland in severa instances, but intragIanduIar metastases were not observed. If Iymph nodes exist within the substance of the submandibuIar salivary gland, or if Iymphatics which drain the ora mucosa pass through the gIandon their way to the cervical lymph nodes, we wouId anticipate their occasional metastatic involvement. Standard textbooks of anatomy and histoIogy were consuIted in an attempt to cIarify the anatomic reIationship of the submandibuIar salivary gIand and the cervical Iymphatic system, but the descriptions were brief and opinions varied. In Tobias’ transIation of Rouviere’s [3] classic treatise on Iymphatic anatomy, we also find differing opinions. Concerning the so-called intracapsular group it is stated, “The possibIe existence of one or severa nodes in the substance of the submaxiIIary gIand, or within its capsuIe in intimate reIation with the gIand, or at a IittIe distance beIow the capsuIe cannot be doubted.” EIsewhere in the same volume, “It is, therefore, probabIe that the intracapsuIar nodes exist in man but exceptionally. Thus, RotoIo examined microscopicahy the serially sectioned submaxiIIary gIands of ten aduIt subjects and found none.” Study of the older Iiterature revealed severa pertinent references. Kuttner [4] reported the resuIts of postmortem injections of the Iymphatics of the tongue in 1898. He stated, “Eine Iymphdruese in der substanz der submaxiharis habe ich nie gefunden (I have never found a Iymph node within the substance of the submaxiIIary [gIand]).” PoIya and von Navratil [T] (1903) performed a similar study of the Iymphatics of the bucca1 mucosa, lips, gingiva, tonsiIIar piIIars and tonsiIs. Their observation concerning the existence of a Iymph node within the submaxiIIary saIivary gIand was: “Wir haben Ietzteres nie beobachIet . . . (The latter, we never have observed) .” 832
Submandibular
SaIivary
It is of historica interest that Crile’s [6] initiaI presentation on neck dissection, at the Southern SurgicaI and GynecoIogic Association in IgoT, occasioned the expression of contlicting opinions. Three technics for the removal of the cervical Iymph nodes were pictorially presented in the published account. One consisted, in essence, of the remova of the Iymph nodes in the submandibular triangIe, the second was comparable to the so-called supraomohyoid dissection but included a portion of the sternomastoid muscIe, and the third was the counterpart of the radica1 neck dissection as it is performed today. His illustrations show the submandibular salivary gland in place after all but a complete dissection. In the subsequent discussion he stated, “I remove the submaxillary salivary glands in the operations in cases in which the cervica1 glands are already invoIved; in cases in which no macroscopic invoIvement has occurred and the gIands are removed as a precautionary measure, the submaxillary salivary glands are not removed.” C. H. Mayo, discussing Crile’s classic presentation, stated, “It has been claimed for a long time that the submaxillary gIand has no lymphatics in it in the shape of glands, but has Iarge lymph ducts, lymph channels, but more recentIy it has been claimed that there is one small gland in the majority of cases in the submaxillary, so that I feel like removing the submaxiIIary in all cases in which I am making a regional dissection to remove en bloc the The paper was aIso dislymphatic system.” cussed by J. SheIton Horsley who noted, “I have found on two occasions . . . a Iymphatic gIand embedded in the submaxiIIary gIand. There was no question about it, because they were practicaIIy surrounded. In one case entireIy; in the other case a smaI1 portion of the lymphatic gIand was showing.” It should be noted that none of the speakers documented their statements relevant to the presence or absence of lymphatics or lymph nodes within the submandibular salivary gIand. Turning to the more recent Iiterature, Martin and associates [7] describe the intragIanduIar submaxillary node, “This node lies within the substance of the submaxillary salivary gland and helps to drain the lloor of the mouth and the midportion of the tongue. AIthough not the most frequentIy involved earIy in metastatic cervical cancer, its presence constitutes one of the reasons for routine removal of the
GIand Specimens submaxiIIary salivary gIand during neck dissection.” Beahrs, Gossel and HoIIinshead [8] have a similar belief: “The submaxiIIary triangIe is cleaned out in the process of radica1 neck dissection in order to remove the submaxillary Iymph nodes which are located especially about the externa1 maxiIIary (facial) artery and the anterior facia1 vein, and in front of, within and behind the submaxillary gIand.” Lore f9] wrote that “lymph nodes are also present within the capsule of the (submaxihary) salivary gland;” yet Wise and Baker [IO] note, “the submandibular nodes form an important group Iying within the digastric triangle close around the submaxillary salivary gland.” A we11 documented recent study is that of Thompson and Bryant [II] who examined IOO parotid and fifty submandibuIar salivary gIands. Two of the Iatter were obtained at postmortem examination, two were removed in treatment of chronic siaIadenitis and the remaining forty-six were from the surgical specimens of suprahyoid neck dissections. All of the parotid specimens were from postmortem examinations. They noted “lymphoid aggregates surrounded by fibrous connective tissue stroma within the gland proper” in twenty-five of IOO normal parotid glands. Some or a11 of the characteristic histoIogic features of Iymph nodes were present in approximately two-thirds of the twenty-five. “UnIike the findings in the parotid gIand, no lymph nodes or encapsulated Iymphoid aggregates were found” in the submandibular saIivary glands. They also studied embryologic specimens and found lymph nodes in the region of the parotid gland in embryos of go mm. and Iarger, but emphasized “the absence of Iymphoid eIements in the submaxiIIary and sublingual glands of the same embryos.” Toker [12] has recentIy reported the resuIts of a painstaking study of radical neck dissection specimens. In twenty-one glands from nineteen patients, he found the submandibular salivary gland was “superficiaIly invaded by direct extension from intoIved Iymph nodes in two specimens, and displayed metastases within its substance on two occasions.” In a personal communication [13] he noted that the latter were discrete foci situated within the interlobular septa in specimens with involved Iymph nodes adjacent to the gland; in one of the two there also was direct superficia1 invasion of the gland from the involved node.
StaIey,
Kaupp
It is his beIief that these foci were “derived from the neighboring Iymph node deposit by retrograde invasion of the saIivary gland He specifically notes that these Iymphatics.” were not metastases within intraglanduIar Iymph nodes; to the best of his recoIIection he has never seen such a node. We must concIude that confusion stiII exists concerning the lymphatic anatomy of the submaxiIIary salivary gIands. To study the reIationship, we have injected pontamine sky bIue into the floor of mouth and/or tongue, in a few patients undergoing neck dissections. In the cases studied thus far the submandibuIar Iymph nodes have shown significant concentration of the dye whiIe the submaxillary salivary gIand maintains its usual appearance. CONCLUSION
The deveIopment of either postradiation or obstructive scIerosing siaIadenitis is of definite clinical significance, because it may be mistaken for a Iymph node metastasis and resuIt in an unnecessary radical neck dissection. If the mechanism of production is kept in mind and the cIinica1 characteristics of the gland are properIy evaIuated, diagnosis is usuaIIy possibIe. HistoIogic confirmation of the cIinica1 impression is essentia1 and may be estabIished by biopsy with a SiIverman needle. Moreover, continued foIIow-up examination is essentiaI, because cervica1 Iymph node metastases may subsequentIy develop. Our evaIuation of the Iymphatic reIationships is of academic interest rather than clinica usefuIness. While we have not seen metastases in the gIand they have been reported by others, albeit rareIy. Moreover, there are Iymph nodes in close reIationship to the gland, though in
and Fischer our materia1 not within its substance. Complete remova of the Iymph node bearing tissue of the upper cervica1 region requires removal of the submandibuIar saIivary gIand. We do not suggest or impIy that the observations recorded herein indicate a modification of the technic of radica1 neck dissection. REFERENCES
H. and SUGARBAKER, E. Cancer of the Aoor of the mouth. Surg. Gynec. I? Obst., 71: 347,
I. MARTIN,
1940. 2. EVANS, J. and ACKER~MA~~, L. Irradiated and obstructed submaxillary sahvary gIands simulating cervical lymph node metastasis. Radiology, 62: 55% 1954. 3. ROUVI&RE, H. Anatomy of the Human Lymphatic System. Ann Arbor, Michigan, 1938. Edwards Brothers, Inc. 4. KOTTNER, H. Ueber die Lgmphgefasse und Lymphdrusen der Zunge mit Beiiehung auf die Verbreituna des Zungencarcinoms. Beitr. klin. Cbir., ZI: 732, 1898. 5. POLYA, A. E. and VON NAVKATIL, D. V. Untersuchungen iiber die Lymphbahnen der WangenschIeimhaut. Deutscbe Ztscbr. Cbir.. 66: 122. 1003. 6. CRILE, G. On the surgica1 treatment of cance; of the head and neck. South. S. Gynec. A., 18: 108, ‘905. 7. MARTIN, H., DEL VALLE, B., EHRLICH, H. and CAHAN, W. Neck dissection. Cancer, 4: 441, 1951. 8. BEAHRS, O., GOSSEL, J. and HOLLINSHEAD, W. Technic and surgical anatomy of radical neck dissection. Am. J. Surg., go: 490, 1955. 9. LoRB, J. An Atlas of Head and Neck Surgerv. Chicago, 1962. W. B. Saunders Co. IO. WISE, R. and BAKER, H. Surgery of the Head and Neck. Chicago, 1958. The Year Book Publishers, Inc. II. THOMPSON, A. S. and BRYANT, H. C., JR. Histogenesis of papiIIary cystadenoma Iymphomatosum (Warthin’s tumor) of the carotid saIivarv gland: Am. J. Patb., 261 807, Igio. 12. TOKER, C. Some observations on the distribution of metastatic squamous carcinoma within cervicaI Iymph nodes. Ann. Surg., 157: 4’9, 1963. 13. TOKER, C. Personal communication.
Chicago, Illinois
representing the experiences of a singIe surgical service, have been restudied. These dissections were performed unilaterahy or bilateraIIy, alone or incontinuity with Iaryngectomy or remova of an intraora1 tumor. The incidence of the various pathoIogic alterations is not significant because it is reIated to the frequency of obstruction of the duct or prior radiotherapy which vary with the nature, Iocation and treatment of the primary tumor. Two to eight sections of each gland, stained with hematoxylin and eosin, were studied. Since this study consisted for the most part of a re-evaIuation of tissues aIready prepared and mounted it is recognized that study of step sections or seria1 sections of aI1 gIands might have produced somewhat different results. The sequeIa of obstruction or radiotherapy generahy invoIve the gland diffuseIy and couId hardIy escape detection, but a small intraglandular node or metastasis could have been missed. Nevertheless, in the latter portion of the study, a more thorough pathoIogic evaluation was accomplished without inff uencing the resuIt.
SUBMANDIBULAR Sahary gIand is removed in a11 cervical Iymph node dissections but is rarely subjected to carefuI histologic evaluation. PathoIogic examination of the surgica1 specimen usuaIIy results in a brief notation that the gIand is normal, or at most, free of metastatic disease. ActualIy, abnormalities occasionahy are observed which are of chnical significance. In order to evaIuate these pathoIogic aIterations the microscopic sections from 150 neck dissections have been reviewed. Our interest was stimuIated initiahy by the process we refer to as scIerosing siaIadenitis, a sequel of irradiation of the submandibuIar salivary gIand or obstruction of its duct. The Iatter may be secondary to invasion by tumor or to operative intervention in which continuity of the duct is interrupted, but the gIand‘is not removed. Regardless of the mechanism of production, the resultant mass is readiIy paIpable beneath the body of the mandibIe and has been interpreted erroneousIy as a Iymph node metastasis. As the study progressed, we deveIoped considerable interest in the Iymphatic reIationships of the submandibular gland. Being famihar with the concept that a lymph node is contained within the substance of the gland, we were impressed by its absence and by the absence of intraglandular metastases, noda or otherwise. It appears that the anatomic reIationship of the submandiburar sahvary gland to the Iymphatic system of the upper cervica1 region is not we11 understood.
T
M.D.,
HE
SCLEROSING
SIALADENITIS
The majority of the submandibuIar gIands were considered normaI, aIthough minor degrees of inflammatory infiltrate or minima1 fibrosis were occasionahy present. With few exceptions the normaI glands were removed from patients who had not received radiotherapy, and whose tumors were not anatomically related to the gland or its duct. It is again pertinent to note that lymph nodes, one or several, subcapsular or intragIanduIar, were not found in any of these specimens. Varying degrees of scIerosing siaIadenitis were found in the obstructed submandibuIar gIands. Microscopically, fibrous repIacement of
MATERIAL The microscopic sections of the submandibuIar sahvary gIands from 150 neck dissections, 831
American
Journal
J Surgery,
Volume: rd.
November
1963
StaIey,
Kaupp
acinar tissue was the ruIe, but the integrity of the remaining acini was preserved. Fibrosis was often extreme. It was predominantIy periIobuIar. The ducts escaped destruction and appeared unduIy prominent; some were dilated and contained mucin producing cells. An inflammatory infiltrate, predominantly Iymphocytic but also containing plasma cells, was almost invariably present. ClinicaIIy apparent sclerosing siaIadenitis is associated most often with tumors arising in or secondariIy invading the anterior portion of the floor of the mouth. This rerationship was noted as Iong ago as rg4o by Martin and Sugarbaker [I]; Evans and Ackerman [2] have recently called attention to the process. We have noted invoIvement of the contralateral gland when remova of a uniIatera1 tumor required an intraora1 incision extending beyond the midIine. Such a resection incIudes the termina1 portion of the contraIatera1 duct which is subsequentIy occIuded in the reconstruction of the mouth. Obstruction, so produced, ordinariIy is not foIIowed by cIinica1 infection. Rather, the gland undergoes progressive fibrosis and parenchyma1 atrophy with the production of a firm, nontender mass which may be mistaken for a metastasis to a submandibuIar lymph node. Sclerosing submandibuIar sialadenitis secondary to irradiation was found most commonIy in patients with tumors arising from the ora mucosa. SeveraI patients, who previousIy received irradiation because of tumors of the Iarynx or pharynx, were found to have similar though generaIIy Iess severe aIterations. The cIinica1 pattern is essentiaIIy the same as that which foI1ows obstruction of a duct. HistoIogicaIIy, the acinar structures showed varying degrees of disruption. CeIIuIar detaiI was poorIy preserved, and in severe cases remaining acinar tissues often appeared as blurred, muItinucIeated cytopIasmic masses. The nucIei were often Iarge and pleomorphic but not hyperchromatic. The ducta epitheIium was Iess affected. IntraIobuIar fibrosis was often prominent. VascuIar changes compatible with the effect of irradiation were frequentIy seen. A more detaiIed study of the histoIogic changes in obstructed and irradiated submandibuIar sabvary gIands, utiIizing additiona staining technics, is in progress.
and Fischer LYMPHATIC SUBMANDIBULAR
RELATIONSHIPS SALIVARY
OF GLAND
In this entire study neither a subcapsular nor an intragIanduIar lymph node was observed. Nor were metastases found in any of these submandibular gIands. (Positive nodes were present in 80 per cent of the specimens.) Tumor had invaded the gIand by direct extension in one instance, and was found in the tissues and nodes adjacent to the gland in severa instances, but intragIanduIar metastases were not observed. If Iymph nodes exist within the substance of the submandibuIar salivary gland, or if Iymphatics which drain the ora mucosa pass through the gIandon their way to the cervical lymph nodes, we wouId anticipate their occasional metastatic involvement. Standard textbooks of anatomy and histoIogy were consuIted in an attempt to cIarify the anatomic reIationship of the submandibuIar salivary gIand and the cervical Iymphatic system, but the descriptions were brief and opinions varied. In Tobias’ transIation of Rouviere’s [3] classic treatise on Iymphatic anatomy, we also find differing opinions. Concerning the so-called intracapsular group it is stated, “The possibIe existence of one or severa nodes in the substance of the submaxiIIary gIand, or within its capsuIe in intimate reIation with the gIand, or at a IittIe distance beIow the capsuIe cannot be doubted.” EIsewhere in the same volume, “It is, therefore, probabIe that the intracapsuIar nodes exist in man but exceptionally. Thus, RotoIo examined microscopicahy the serially sectioned submaxiIIary gIands of ten aduIt subjects and found none.” Study of the older Iiterature revealed severa pertinent references. Kuttner [4] reported the resuIts of postmortem injections of the Iymphatics of the tongue in 1898. He stated, “Eine Iymphdruese in der substanz der submaxiharis habe ich nie gefunden (I have never found a Iymph node within the substance of the submaxiIIary [gIand]).” PoIya and von Navratil [T] (1903) performed a similar study of the Iymphatics of the bucca1 mucosa, lips, gingiva, tonsiIIar piIIars and tonsiIs. Their observation concerning the existence of a Iymph node within the submaxiIIary saIivary gIand was: “Wir haben Ietzteres nie beobachIet . . . (The latter, we never have observed) .” 832
Submandibular
SaIivary
It is of historica interest that Crile’s [6] initiaI presentation on neck dissection, at the Southern SurgicaI and GynecoIogic Association in IgoT, occasioned the expression of contlicting opinions. Three technics for the removal of the cervical Iymph nodes were pictorially presented in the published account. One consisted, in essence, of the remova of the Iymph nodes in the submandibular triangIe, the second was comparable to the so-called supraomohyoid dissection but included a portion of the sternomastoid muscIe, and the third was the counterpart of the radica1 neck dissection as it is performed today. His illustrations show the submandibular salivary gland in place after all but a complete dissection. In the subsequent discussion he stated, “I remove the submaxillary salivary glands in the operations in cases in which the cervica1 glands are already invoIved; in cases in which no macroscopic invoIvement has occurred and the gIands are removed as a precautionary measure, the submaxillary salivary glands are not removed.” C. H. Mayo, discussing Crile’s classic presentation, stated, “It has been claimed for a long time that the submaxillary gIand has no lymphatics in it in the shape of glands, but has Iarge lymph ducts, lymph channels, but more recentIy it has been claimed that there is one small gland in the majority of cases in the submaxillary, so that I feel like removing the submaxiIIary in all cases in which I am making a regional dissection to remove en bloc the The paper was aIso dislymphatic system.” cussed by J. SheIton Horsley who noted, “I have found on two occasions . . . a Iymphatic gIand embedded in the submaxiIIary gIand. There was no question about it, because they were practicaIIy surrounded. In one case entireIy; in the other case a smaI1 portion of the lymphatic gIand was showing.” It should be noted that none of the speakers documented their statements relevant to the presence or absence of lymphatics or lymph nodes within the submandibular salivary gIand. Turning to the more recent Iiterature, Martin and associates [7] describe the intragIanduIar submaxillary node, “This node lies within the substance of the submaxillary salivary gland and helps to drain the lloor of the mouth and the midportion of the tongue. AIthough not the most frequentIy involved earIy in metastatic cervical cancer, its presence constitutes one of the reasons for routine removal of the
GIand Specimens submaxiIIary salivary gIand during neck dissection.” Beahrs, Gossel and HoIIinshead [8] have a similar belief: “The submaxiIIary triangIe is cleaned out in the process of radica1 neck dissection in order to remove the submaxillary Iymph nodes which are located especially about the externa1 maxiIIary (facial) artery and the anterior facia1 vein, and in front of, within and behind the submaxillary gIand.” Lore f9] wrote that “lymph nodes are also present within the capsule of the (submaxihary) salivary gland;” yet Wise and Baker [IO] note, “the submandibular nodes form an important group Iying within the digastric triangle close around the submaxillary salivary gland.” A we11 documented recent study is that of Thompson and Bryant [II] who examined IOO parotid and fifty submandibuIar salivary gIands. Two of the Iatter were obtained at postmortem examination, two were removed in treatment of chronic siaIadenitis and the remaining forty-six were from the surgical specimens of suprahyoid neck dissections. All of the parotid specimens were from postmortem examinations. They noted “lymphoid aggregates surrounded by fibrous connective tissue stroma within the gland proper” in twenty-five of IOO normal parotid glands. Some or a11 of the characteristic histoIogic features of Iymph nodes were present in approximately two-thirds of the twenty-five. “UnIike the findings in the parotid gIand, no lymph nodes or encapsulated Iymphoid aggregates were found” in the submandibular saIivary glands. They also studied embryologic specimens and found lymph nodes in the region of the parotid gland in embryos of go mm. and Iarger, but emphasized “the absence of Iymphoid eIements in the submaxiIIary and sublingual glands of the same embryos.” Toker [12] has recentIy reported the resuIts of a painstaking study of radical neck dissection specimens. In twenty-one glands from nineteen patients, he found the submandibular salivary gland was “superficiaIly invaded by direct extension from intoIved Iymph nodes in two specimens, and displayed metastases within its substance on two occasions.” In a personal communication [13] he noted that the latter were discrete foci situated within the interlobular septa in specimens with involved Iymph nodes adjacent to the gland; in one of the two there also was direct superficia1 invasion of the gland from the involved node.
StaIey,
Kaupp
It is his beIief that these foci were “derived from the neighboring Iymph node deposit by retrograde invasion of the saIivary gland He specifically notes that these Iymphatics.” were not metastases within intraglanduIar Iymph nodes; to the best of his recoIIection he has never seen such a node. We must concIude that confusion stiII exists concerning the lymphatic anatomy of the submaxiIIary salivary gIands. To study the reIationship, we have injected pontamine sky bIue into the floor of mouth and/or tongue, in a few patients undergoing neck dissections. In the cases studied thus far the submandibuIar Iymph nodes have shown significant concentration of the dye whiIe the submaxillary salivary gIand maintains its usual appearance. CONCLUSION
The deveIopment of either postradiation or obstructive scIerosing siaIadenitis is of definite clinical significance, because it may be mistaken for a Iymph node metastasis and resuIt in an unnecessary radical neck dissection. If the mechanism of production is kept in mind and the cIinica1 characteristics of the gland are properIy evaIuated, diagnosis is usuaIIy possibIe. HistoIogic confirmation of the cIinica1 impression is essentia1 and may be estabIished by biopsy with a SiIverman needle. Moreover, continued foIIow-up examination is essentiaI, because cervica1 Iymph node metastases may subsequentIy develop. Our evaIuation of the Iymphatic reIationships is of academic interest rather than clinica usefuIness. While we have not seen metastases in the gIand they have been reported by others, albeit rareIy. Moreover, there are Iymph nodes in close reIationship to the gland, though in
and Fischer our materia1 not within its substance. Complete remova of the Iymph node bearing tissue of the upper cervica1 region requires removal of the submandibuIar saIivary gIand. We do not suggest or impIy that the observations recorded herein indicate a modification of the technic of radica1 neck dissection. REFERENCES
H. and SUGARBAKER, E. Cancer of the Aoor of the mouth. Surg. Gynec. I? Obst., 71: 347,
I. MARTIN,
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