Parotid / Submandibular / Sublingual

Parotid

The parotid gland is the largest salivary gland in the body.  The other major salivary glands are the submandibular (under the jaw) and the sublingual (under the tongue).  These glands are paired i.e. there is one on each side.  Also there are numerous minor glands in the lining of the mouth and throat.

Infection of the parotid

The commonest infection is mumps, a viral infection which most experience in childhood.  It is self-limiting and requires only supportive measures.

Acute bacterial infections are usually associated with reduced salivary flow which allows bacteria to spread from the mouth up the parotid duct.  This can occur with dehydration or blockage of the duct.  Bacterial infections cause tense and painful parotid swelling and are treated with hydration, antibiotics and elimination of ductal obstruction.  Occasionally  abscesses can form which require surgical drainage.

Chronic or recurring parotid swelling with discomfort and infection is suggestive of an underlying disorder such as an autoimmune condition. In this, the saliva secreting cells and the cells lining the ducts are slowly damaged by the body's immune system. This results in narrowing of some parts of the ductal system and dilatation of others and thereby a reduction in salivary flow. What saliva is produced is not excreted into the mouth effectively and the gland swells uncomfortably. It is ripe for infection from bacteria in the mouth.

 

What is a parotid tumour?

"Tumour" simply means a lump or mass. A tumour can be benign or malignant and fortunately most parotid lumps are benign. Most are situated in the “tail” of the gland behind the angle of the jaw in the upper neck. 

The commonest tumour is the pleomorphic adenoma which is benign and appears as a slowly growing, firm lump. This will relentlessly grow over many years and, if left for too long, can become quite disfiguring and may also turn malignant.

The next most common tumour is the Warthin's tumour, a benign slowly growing soft lump that may fluctuate in size.

Malignant parotid tumours

About 10% of tumours arising from the parotid gland are malignant . The most common in New Zealand is a metastasis within a  lymph node from a skin cancer of the head or face.  Less commonly the malignant tumours are primarily derived from parotid tissue. 

Malignant tumours may be associated with other enlarged nodes in the parotid or neck.  As they grow they may involve the facial nerve causing weakness of part or all of that side of the face.  They may also involve the overlying skin.  Despite these features the vast majority of parotid cancers are successfully treated with surgery and radiotherapy.

What is parotid cancer?

A parotid cancer is a malignant tumour within the parotid gland. About 10% of all parotid tumours are malignant.

Types of parotid cancer

• Lymph node metastases from skin cancer of the scalp or face. Both melanoma and squamous cell carcinoma can do this.
• Muco-epidermoid - can be low grade to high grade depending on how aggressive the cells look under the microscope.
• Adenoid cystic - generally a slow-growing cancer that has a tendency to invade along nerves. 
• Others such as acinic cell are low grade tumours 
• Lymphoma- also rare but very treatable with radiotherapy and chemotherapy

Presentation of parotid cancer

Usually presents as one or more lumps in the parotid. Many are slow growing and have been present for months while others can come up quickly over a few weeks. They are generally noticed one day when looking in the mirror, feeling one’s neck or are pointed out by a friend. Parotid cancer is usually painless. 

The cancer can occasionally invade adjacent structures such as a nerve to the face causing weakness of part of the face, or it can involve the overlying skin or the jaw.

 

Treatment of parotid cancer

Nearly all parotid cancers can be treated surgically even those that are involving adjacent structures. Occasionally a part or all of the facial nerve will need to be removed if it is involved by cancer. Nerve grafting in this situation can give reasonable recovery of function although it is never perfect. Frequently it is necessary to also remove neck nodes on the same side as there is a significant risk of metastatic involvement. Following surgery most patients will receive radiotherapy to reduce the chance of recurrence. 

 

 

Parotid surgery is required when there is a lump in the parotid gland.  The aims of surgery are:

• to determine the nature of the lump
• to  prevent a benign lump from becoming malignant
• because a benign lump will relentlessly grow and become more difficult to remove later

Parotidectomy is done under a general anesthetic so that the patient is asleep and unaware during the operation. Generally the first part of the operation is dissecting between the ear and the gland to find the facial nerve which runs through the gland and divides into branches to the various muscles in the face. By finding the nerve first, the chance of injury to it is minimised. The second part of the operation consists of dissecting the abnormal parotid tissue away from the nerve.

 

The procedure takes about 2 hours but can be longer depending on its complexity. The hospital stay is 1-2 days and planned time off work should be 10-14 days.

What investigations?

physical examination – to determine the size of the parotid and to detect enlarged lymph nodes.  To check facial nerve function

If you have a parotid lump that is mobile and has the clinical features of the common pleomorphic adenoma then Dr McIvor may advise that tests are unlikely to change his advice to have a parotidectomy.  However when there is some doubt as to the lump’s nature or position he may advise a needle biopsy and imaging.

1. blood tests – there are none specific to the parotid but you may be sent for routine blood tests as part of the anaesthetic work-up prior to surgery.
2. ultrasound scan – to determine the characteristics of the gland and any lumps and to look at the adjacent neck nodes.  Dr McIvor may this in his clinic.
3. CT or MRI scans – these give better detail of deeper structures and nodes and may be requested.
4. fine needle biopsy of a lump – this is done under local anaesthetic in the clinic.  Often ultrasound is used to direct the needle to a specific area of the parotid.  The test is occasionally a little uncomfortable but usually not.  Cells are aspirated and smeared on a slide.  Results take about a week and can be a useful guide as to the nature of the lump.

What are the treatment options? 

surgery   

Basically if there is a lump in the parotid that has been present for more than a few weeks and is not clearly an inflamed lymph node it is best removed as needle biopsies are not 100% accurate.  Remember that even benign tumours cause problems – they continue to grow making surgery later more difficult and some can undergo malignant transformation.

observation

This is a reasonable option where the lump has been present for years, is growing slowly, and the needle biopsy indicates it is benign ( remember that these biopsies are wrong in about 5% i.e the tumour is malignant when the biopsy is reported as benign).  It is also reasonable in the elderly or frail when the biopsy is benign.  It is not reasonable in any but the very frail when the biopsy indicates a high grade malignancy.

When and where will the operation be done?

What must I do in the week(s) before surgery? ( insurance, hospital, family, work)

What do I do on the day of surgery and what shall I bring to the hospital?

What will happen when I go to theatre?

What will happen when I get back to the ward following surgery?

Is it a safe operation and what are the side effects?

Dr McIvor has done hundreds of  parotid operations.  Usually only that part of the gland containing the tumour is removed.  Even when most of the parotid is removed there is no noticeable reduction in saliva as the opposite parotid as well as the other salivary glands continue to produce.

The nerve to the face runs through the middle of the parotid gland dividing into branches to various parts of the face as it does so.  To preserve the nerve during parotidectomy, the nerve is found as it enters the parotid and followed through the gland, dissecting the tumour and surrounding gland away from the nerve until removed.  The likelihood of temporary nerve injury with a weakness of part of the face is around 5%.  The risk of permanent weakness of one half of the face in the absence of malignant invasion is

There may be a change in facial contour at the angle of the jaw if most parotid tissue is removed as it acts as a soft-tissue filler over the jaw-line.

Will I have neck stiffness, restricted shoulder movement or pain?

You will feel some discomfort around your jaw-line and experience some stiffness with jaw openeing but you will be given some medication to help ease this. Pain relief may be given in different ways, such as injections, liquid medicine or tablets. Most patients say the discomfort is not as bad as they expected, and after the first day are up and walking around.

Following discharge on the first or second day Dr McIvor prescribes paracetamol and an anti-inflammatory for 5 days which suffices for any discomfort.  After a few weeks you should be back to a good standard of neck and jaw function. 

What are the costs for parotidectomy?

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist and the hospital and are to be paid separately. 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.

Will I have a scar?

The incision is a modified facelift incision and heals to leave a fine scar which is not very noticeable

What will I look like after parotid surgery and what will I be able to do?

You will have a scar running from immediately in front of your ear gently curving around the earlobe and extending somewhat into the neck . This will be covered by a small white dressing so that it is not visible.  Dr McIvor uses dissolving sutures and skin tapes so that few if any sutures need to be removed.

You will have a small drain from your wound to collect wound fluid which naturally occurs following your surgery. The drains are small plastic tubes which are inserted into the neck at the end of your operation. The long length of tubing outside the neck is attached to a plastic collection bottle into which the fluid drains. Wound drains help to speed up wound healing and reduce infection.

1. The drain is not painful can be carried around with you. It will usually be removed by a nurse a day or two after your operation when the drainage is minimal.   Drain removal is not painful.

2. You will feel some discomfort and stiffness around your jaw but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.

3. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.

4. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed.

5. Following your operation you may not feel very sociable so it is wise to restrict visitors.

   Will I have a sore neck?

   When you wake from the anesthetic you will find that the skin of your neck, jaw line and ear is quite numb as the anesthetist inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

   You may find that your jaw is uncomfortable when you open your mouth wide.  This discomfort usually settles in a few days.

   You will be given medication to take home to relieve the discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

   Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place.

   Will it affect my eating and drinking?

   As there is likely to be some residual parotid tissue, it is best to avoid citrus fruit and spicey foods in the first week so that saliva is not secreted excessively into the wound which can delay healing.

   What care do I need to take regarding my neck wound?

   Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound.

   After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

   The pressure of rubbing the cream in will also help to soften the scar.

   If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP.

   What rest do I need and when should I return to work?

   You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

   You will probably need to take one to two weeks off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for two weeks and then you should see your GP if more time is required.

   What about my medications and tablets?

   Please continue to take the medication you have been prescribed and ensure that you have a good supply. If you are unsure about any of the tablets you need to take, please check this with a nurse before you go home. Repeat prescriptions can be obtained from your GP.

   What follow-up will there be?

   Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and to discuss the laboratory report of the resected parotid. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 4887349) if you do not receive one shortly following discharge.

   If you have had parotid surgery for cancer then you may need further treatment (e.g. radiotherapy) and an appointment will be arranged for you with an oncologist  to discuss this further.  Regular checks with Dr McIvor will be for at least 5 years.

    

The submandibular gland is the second largest salivary gland in the body.  The other major salivary glands are the parotid (in front of and below the ear) and the sublingual (under the tongue).  These glands are paired i.e. there is one on each side.  Also there are numerous minor glands in the lining of the mouth and throat.

Size and location

The submandibular gland is situated under the jaw and weighs about 5g.  It is soft and contributes to the contour of the neck below the jaw-line.

Function

The submandibular gland excretes saliva into a duct that empties into the mouth under the tongue.  Saliva lubricates the mouth and throat, protects the teeth, has antibacterial properties and helps to digest food.

Infection of the submandibular gland

Recurring submandibular swelling and discomfort that lasts for minutes or hours after eating indicates ductal obstruction either from a stone (also known as a calculus) , or a narrowing (also known as a stricture or stenosis) of the duct or its opening under the tongue. The reduced salivary flow can allow bacteria to spread from the mouth up the submandibular duct.

Bacterial infections cause tense and painful submandibular swelling and are treated by elimination of ductal obstruction, hydration, and antibiotics.  Occasionally  abscesses can form which require surgical drainage.

Stones (calculi) form because of the high calcium content in saliva from the submandibular gland - they are less likely in the parotid gland which excretes a lower concentration of calcium

What is a submandibular tumour?

"Tumour" simply means a lump or mass. A tumour can be benign or malignant and about half of all submandibular lumps are benign. Dr McIvor will be keen to determine whether the lump arises within the submandibular gland itself or whether it is a lymph node or other lump lying against it.

Of those lumps arising within the gland, the commonest tumour is the pleomorphic adenoma which is benign and appears as a slowly growing, firm lump. This will relentlessly grow over many years and, if left for too long, can become quite disfiguring and may also turn malignant.

Often the lump does not arise within the submandibular gland itself but lies adjacent to it. The commonest are lymph nodes that are swollen either by infection or by cancer that has spread from an adjacent area such as the mouth or skin.

 

Malignant submandibular tumours

About 40% of tumours arising within the submandibular gland are malignant. The most common cancers are the so-called muco-epidermoid and adenoid cystic carcinomas which are usually but not always low-grade cancers. They are usually effectively treated by surgery and sometimes radiotherapy is required as well.

Malignant tumours may be associated with other enlarged nodes in the neck.  As they grow they may involve the branch of the facial nerve to the lower lip causing weakness of that part of the lip which sits higher than normal.  They may also involve the overlying skin.  Despite these features the majority of submandibular cancers are successfully treated with surgery and radiotherapy.

 

What is submandibular cancer?

A submandibular cancer is a malignant tumour within or adjacent to the submandibular gland. About 50% of all submandibular tumours are malignant.

Types of submandibular cancer

• Lymph node metastases from skin cancer of the scalp or face. Both melanoma and squamous cell carcinoma can do this.
• Muco-epidermoid - can be low grade to high grade depending on how aggressive the cells look under the microscope.
• Adenoid cystic - generally a slow-growing cancer that has a tendency to invade along nerves. 
• Others such as acinic cell are usually low grade tumours 
• Lymphoma- also rare but very treatable with radiotherapy and chemotherapy

Presentation of submandibular cancer

Usually presents as one or more lumps under the jaw. Many are slow growing and have been present for months while others can come up quickly over a few weeks. They are generally noticed one day when looking in the mirror, feeling one’s neck or are pointed out by a friend. Submandibular cancer is usually painless. The image on the left shows a malignant lymph node from skin cancer.

Patients may already have involved nodes in the neck at presentation .

The cancer can occasionally invade adjacent structures such as the nerve to the lower lip causing that side of the lip to be higher than normal, or it can involve the overlying skin or the jaw.

 

Treatment of submandibular cancer

Nearly all submandibular cancers can be treated surgically even those that are involving adjacent structures. Occasionally the branch of the facial nerve that innervates the lower lip will need to be removed if it is involved by cancer. Frequently it is necessary to also remove neck nodes on the same side as there may be a significant risk of metastatic involvement. Following surgery most patients will receive radiotherapy to reduce the chance of recurrence. 

 

---

Submandibular surgery is required when there is a lump in or adjacent to the submandibular gland.  The aims of surgery are:

• to determine the nature of the lump
• to  prevent a benign lump from becoming malignant
• because a benign lump will relentlessly grow and become more difficult to remove later
  
  

Submandibular surgery is done under a general anesthetic so that the patient is asleep and unaware during the operation. Generally the operation commences by dissecting between the loose tissues under the skin and the gland itself so that the tiny branch of the facial nerve that supplies the muscles of the lower lip is protected. The submandibular gland and any abnormal lump is then dissected away from the surrounding structures including the jaw and the nerve that supplies sensation to that side of the tongue. Once removed the gland is sent for examination by a pathologist (the report takes one week). A small drain is inserted and the wound closed with a dissolving suture.

The procedure takes about 1 hour but can be longer depending on its complexity. The hospital stay is 1 day and planned time off work should be 7-10 days.

What investigations?

physical examination – To determine whether the lump represents the entire gland or is a discrete lump either within the gland or adjacent to it. To determine whether the submandibular duct that drains saliva from the gland is blocked. To detect lymph nodes and to examine areas that drain lymph into the submandibular area (the mouth and skin of the face) .

If you have a submandibular lump that is mobile and has the clinical features of a lump within the gland itself then Dr McIvor may advise that tests are unlikely to change his advice to have the gland removed.  However when there is some doubt as to the lump’s nature or position he may advise imaging and a needle biopsy.

1. ultrasound scan – to determine the characteristics of the gland and any lumps and to look at the adjacent neck nodes. This will help determine whether the whole gland is swollen as when the duct is blocked,or whether the lump is discrete and within the gland or lying outside and adjacent to it. Dr McIvor may do this scan in his clinic.
2. XRays - when there is concern about the possibility of salivary calculi or stones that are blocking the duct and causing the whole gland to swell.
3. blood tests – there are none specific to the submandibular gland but you may be sent for routine blood tests as part of the anaesthetic work-up prior to surgery.
4. CT or MRI scans – these give better detail of deeper structures and nodes and may be requested.
5. fine needle biopsy of a lump – this is done under local anaesthetic in the clinic.  Often ultrasound is used to direct the needle to a specific area.   The test is occasionally a little uncomfortable but usually not.  Cells are aspirated and smeared on a slide.  Results take about a week and can be a useful guide as to the nature of the lump.

What are the treatment options? 

surgery   

Basically if there is a lump in the submandibular area that has been present for more than a few weeks and is not clearly an inflamed lymph node it is best removed as needle biopsies are not 100% accurate.  Remember that even benign tumours cause problems – they continue to grow making surgery later more difficult and some can undergo malignant transformation.

observation

This is a reasonable option where the lump has been present for years, is growing slowly, and the needle biopsy indicates it is benign (remember that these biopsies are wrong in about 5% i.e the tumour is malignant when the biopsy is reported as benign).  It is also reasonable in the elderly or frail when the biopsy is benign.  It is not reasonable in any but the very frail when the biopsy indicates a high grade malignancy.

When and where will the operation be done?

What must I do in the week(s) before surgery?( insurance, hospital, family, work)

What do I do on the day of surgery and what shall I bring into hospital?

What will happne when I go to theatre?

What will happen when I get back on the ward following surgery?

Is it a safe operation and what are the side effects?

Dr McIvor has done hundreds of  submandibular operations.  There is no noticeable reduction in saliva as the opposite submandibular gland as well as the other salivary glands continue to produce.

Will it affect my face?

There is a very small risk of injury to the nerve to the lower lip muscles (marginal mandibular nerve). This nerve lies just below the jaw-line and is at risk from an incision in this location. Injury could cause a lifting of the lower lip on that side when smiling or opening the mouth widely. Occasionally there can be a tendency to spill liquid from the corner of the mouth when drinking. The likelihood of a permanent injury is very small.

Will I have neck stiffness, restricted jaw movement or pain?

You will feel some discomfort around your jaw-line and experience some stiffness with jaw opening but you will be given some medication to help ease this. Pain relief may be given in different ways, such as injections, liquid medicine or tablets. Most patients say the discomfort is not as bad as they expected, and after the first day are up and walking around.

Following discharge on the first or second day Dr McIvor prescribes paracetamol and an anti-inflammatory for 5 days which suffices for any discomfort.  After a few weeks you should be back to a good standard of neck and jaw function. 

Will I have a scar?

The incision is a modified facelift incision and heals to leave a fine scar which is not very noticeable

What are the costs for Submandibular surgery?

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist and the hospital and are to be paid separately. 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.

What will I look like after submandibular surgery and what will I be able to do?

1. You will have a small scar in your neck about 2cm below the jaw. This will be covered by a small white dressing so that it is not visible.  Dr McIvor uses dissolving sutures and skin tapes so that few if any sutures need to be removed.

2. You will have a small plastic drainage tube from your wound collecting wound fluid which naturally occurs following your surgery. The long length of tubing outside the neck is attached to a plastic collection bottle into which the fluid drains. Wound drains help to speed up wound healing and reduce infection.

3. The drain is not painful and can be carried around with you. It will usually be removed by a nurse the day after your operation when the drainage is minimal.   Drain removal is not painful. Occasionally patients go home with their drains and a district nurse is arranged to check on them at the patient's home and to remove them when drainage is minimal.

4. You will feel some discomfort and stiffness around your jaw but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.

5. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.

6. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed.

7. Will I have a sore neck?

   When you wake from the anesthetic you will find that the skin of your neck, jaw line and ear is quite numb as the anesthetist inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

   You may find that your jaw is uncomfortable when you open your mouth wide.  This discomfort usually settles in a few days.

   You will be given medication to take home to relieve the discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

   Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place.

   Will it affect my eating and drinking?

   As there is likely to be some residual parotid tissue, it is best to avoid citrus fruit and spicey foods in the first week so that saliva is not secreted excessively into the wound which can delay healing.

   What care do I need to take regarding my neck wound?

   Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound. After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

   The pressure of rubbing the cream in will also help to soften the scar.

   If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP.

   What rest do I need and when should I return to work?

   You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

   You will probably need to take one week off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for two weeks and then you should see your GP if more time is required.

   What about my medications and tablets?

   Please continue to take the medication you have been prescribed and ensure that you have a good supply. If you are unsure about any of the tablets you need to take, please check this with a nurse before you go home. Repeat prescriptions can be obtained from your GP.

   What follow-up will there be?

   Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and to discuss the laboratory report. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 488 7349) if you do not receive one shortly following discharge.

   If you have had submandibular surgery for cancer then you may need further treatment (e.g. radiotherapy) and an appointment will be arranged for you with an oncologist  to discuss this further.  Regular checks with Dr McIvor will be for at least 5 years.

   You will probably need to take one week off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for two weeks and then you should see your GP if more time is required.

   You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

 

The sublingual gland is a mucus secreting gland under the tongue.  These glands are paired i.e. there is one on each side. 

Function

The sublingual gland excretes saliva consisting mainly of mucus into tiny ducts that empty into the mouth under the tongue.  Saliva lubricates the mouth and throat, protects the teeth, has antibacterial properties and helps to digest food.

Problems

The commonest sublingual gland abnormality is leakage of mucus into surrounding tissues. The mucus produces a cystic swelling like a bubble in the floor of mouth where it is called a ranula(from rana, the italian word for frog), or a soft swelling in the neck under the jaw where it is known as a plunging ranula. For some reason ranulae (plural of ranula) are more common in Polynesians and for this reason Auckland has the highest incidence of ranulae of any city in the world!

Occasionally tumours develop in the sublingual gland requiring removal. A tumour appears as a firm lump under the tongue. If malignant there may also be numbness of that side of the tongue.

What investigations?

physical examination – If there is a ranula or plunging ranula Dr Mcivor will look and feel inside the mouth to determine whether there is any swelling of the gland itself. If the swelling is in the mid-line it is important to determine which sublingual gland is leaking. If there is a lump in the gland it is important to determine whether the lump represents the entire gland, or is a discrete lump either within or next to the gland.

Dr McIvor may advise that tests are unlikely to change his advice to have the gland removed.  However when there is some doubt as to the problem he may advise imaging and a needle biopsy.

1. blood tests – there are none specific to the submandibular gland but you may be sent for routine blood tests as part of the anaesthetic work-up prior to surgery.
2. CT or MRI scans – these give better detail of deeper structures and nodes and may be requested.
3. fine needle biopsy of a lump or swelling – this is done under local anaesthetic in the clinic.  Often ultrasound is used to direct the needle to a specific area.   The test is occasionally a little uncomfortable but usually not.  Cells are aspirated and smeared on a slide.  Results take about a week and can be a useful guide as to the nature of the problem.

 

---

Sublingual gland surgery is usually required when there is mucus leaking from the gland into surrounding tissues. When the mucus leaks just under the tongue it causes a swelling like the underbelly of a frog. This is called a ranula. Often the mucus tracks down into the neck causing a soft swelling under the jaw where it is called a plunging ranula.

Surgery may also be required to remove a lump or tumour within the sublingual gland in order to:

• determine the nature of the lump 
• prevent a benign lump from becoming malignant
• because a benign lump will relentlessly grow and become more difficult to remove later
  
  
  

Sublingual gland surgery is done under a general anesthetic so that the patient is asleep and unaware during the operation. Generally the operation commences by gently propping the jaw open to display the floor of the mouth under the tongue. The gland is dissected away from the surrounding structures including the nerves that supply sensation and movement to that side of the tongue. The duct of the submandibular gland is also gently dissected away. Once removed, the gland is sent for examination by a pathologist (the report takes one week). A small drain is inserted and the wound closed with a dissolving suture.

 

The procedure takes about 1 hour but can be longer depending on its complexity.

Occasionally the sublingual gland problem is such that it affects the adjacent submandibular gland requiring the removal of both glands. This requires an incision in the neck below the jaw and leaves a fine scar. 

The hospital stay is 1 day and planned time off work should be 7-10 days.

 

When and where will the operation be done?

What must I do in the week(s) before surgery? ( insurance, hospital, family, work)

What do I do on the day of surgery and what shall I bring to hospital?

What will happen when I go to theatre?

What will happen when I get back to the ward?

Is it a safe operation and what are the side effects?

Dr McIvor has done many sublingual operations.  There is no noticeable reduction in saliva as the opposite sublingual gland and other salivary glands continue to produce.

The main risks with the operation are damage to nerves next to the sublingual gland. The lingual nerve which supplies sensation to the tongue can be affected causing tingling on that side of the tongue. This settles within a few days or weeks. Greater injury to the nerve is very unusual but is more likely if there is a tumour present requiring a wider removal of tissue in the floor of mouth. This can result in numbness and/or weakness of that side of the tongue. This has minimal if any effect on speech.

Every operation carries a small (1%) chance of bleeding in the first 6 hours or so after the procedure. This can require a return to the operating room and another anaesthetic to control the bleeding vessel.

Will it affect my face?
For standard sublingual gland surgery your face will look the same although there may be some swelling under the jaw for a few days. There may be a small drain coming out through the skin under the jaw for a day after the operation. When this is removed a small puncture wound is present under the jaw that heals over about 10 days. It is simply covered with a small sticking plaster.

Occasionally the sublingual gland problem is more extensive and extends into the submandibular area. In this situation the submandibular gland may also have to be removed through the neck via a separate incision. 

Will I have a scar?

There is no external scar unless the submandibular gland is also removed. This is occasionally necessary for a plunging ranula when the sublingual gland extends too far into the neck. It is also occasionally required for the excision of a sublingual gland tumour.

What will I look like after sublingual surgery and what will I be able to do?

1. The wound will be in our mouth so you will look the same although there may be a small drain that comes through the skin under your jaw .

2. The small drain collects fluid which naturally occurs following your surgery. It is a small plastic tube which is inserted into the neck at the end of the operation and is attached to a plastic collection bottle into which the fluid drains. The drain helps to speed up wound healing and reduce infection.

3. The drain is not painful can be carried around with you. It will usually be removed by a nurse a day after your operation when the drainage is minimal.   Drain removal is not painful.

4. You will feel some discomfort and stiffness around your jaw but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.

5. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.

6. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed.

 

Will I have a sore mouth or neck?

When you wake from the anesthetic you will find that the inside of your mouth on that side is quite numb as the Dr McIvor inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

You may find that your mouth is uncomfortable when you poke out your tongue or swallow.  This discomfort usually settles in a few days.

You will be given medication to take home to relieve the discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

That side of your mouth may be tender to touch, with some numbness, which will gradually resolve as healing takes place.

Will it affect my eating and drinking?

As there will be an incision with sutures under the tongue it is best to have a soft diet for the first week. You will need to keep your mouth clean with frequent salt and water mouthwashes over that week.

What care do I need to take regarding my mouth wound?

As there will be an incision with sutures under the tongue it is best to have a soft diet for the first week. You will need to keep your mouth clean with frequent salt and water mouthwashes.

If the wound area becomes increasingly painful, red or swollen or you notice any swelling in the neck then please seek medical advice from Dr McIvor or your GP.

What rest do I need and when should I return to work?

You will need to take it easy while your mouth wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel more comfortable and you will soon be able to enjoy your normal activities.

You will probably need to take one to two weeks off work depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for two weeks and then you should see your GP if more time is required.

What about my medications and tablets?

Please continue to take the medication you have been prescribed and ensure that you have a good supply. If you are unsure about any of the tablets you need to take, please check this with a nurse before you go home. Repeat prescriptions can be obtained from your GP.

What follow-up will there be?

Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and to discuss the laboratory report of the resected gland. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 4887349) if you do not receive one shortly following discharge.