Surgeon's Corner: Salivary Mucocele

Presentation

A 2-year-old vizsla presented with history of a recurrent pharyngeal mucocele. On oral examination, just below the left tonsil, a large, soft, fluctuant, nonpainful mass is seen. On the ventral aspect of the swelling is a small scar where the referring veterinarian previously attempted a marsupialization. Marsupialization is occasionally successful, but the majority of cases require ipsilateral removal of both sublingual and mandibular salivary glands.

Surgery

The sublingual and mandibular salivary glands lie at the bifurcation of the jugular vein as it divides into the external maxillary and sublingual veins. The incision is made directly over the salivary gland, being careful not to extend the incision too far caudally to engage the commissure of the jugular vein bifurcation. The platysma muscle (which can be quite robust in large-breed dogs, such as this patient) is incised. Directly under this muscle is the capsule for the sublingual and mandibular salivary glands. The glands are carefully peeled out of the interior of the capsule. The major blood supply to the glands is located on its dorsomedial aspect. These vessels are identified and either ligated or cauterized, allowing improved visualization of the duct. Taking care to remove both the monostomatic and the polystomatic portions of the sublingual salivary gland decreases the chances of recurrence of the mucocele. As the duct is dissected deeper, the polystomatic branches appear. Allis tissue forceps are used to apply caudal traction on the gland, allowing blunt dissection of the duct away from the connective tissue as the duct continues below the digastricus muscle and along the medial aspect of the mandibular ramus. The lingual artery courses across the deep aspect of the duct, and this is identified and retracted for further dissection to occur.

Once the pharyngeal mucocele is exposed, it is entered so the saliva can be aspirated, thus facilitating visualization during the deeper dissection of the duct. This ensures removal of the remaining polystomatic glands. Once exposure of the duct is complete, it is ligated using a stapling device or grasped and pulled out via traction. A penrose drain is placed in the remaining mucocele cavity making certain it exits at the ventral most aspect of the neck.  Wound closure is performed in three layers: first, the platysma muscle; then, the subcutaneous tissue; and finally, the skin. Some surgeons combine the platysma and subcutaneous closures. All layers are closed using a simple continuous pattern with synthetic absorbable suture material.

Outcome

Prior to extubation, an oral examination revealed that the pharyngeal mucocele was completely gone. The patient had fully recovered by the next day. The drain is generally removed between 6 and 12 hours postoperatively. Complete sublingual and mandibular salivary gland removal provides an excellent prognosis for patients with salivary gland mucocele.

This video was authored by Howard B Seim III, DVM, DACVS. Other surgical videos are available through VideoVet.

Surgeon’s Corner is intended as a forum for those with specialized expertise to share their approaches to various techniques and procedures. The content consequently reflects one expert’s approach and is not subject to peer review.