Submandibular Gland Transfer: A Potential Imaging Pitfall - PubMed (original) (raw)

. 2018 Jun;39(6):1140-1145.

doi: 10.3174/ajnr.A5609. Epub 2018 Mar 29.

Affiliations

Submandibular Gland Transfer: A Potential Imaging Pitfall

X Wu et al. AJNR Am J Neuroradiol. 2018 Jun.

Abstract

Background and purpose: The Seikaly and Jha submandibular gland transfer surgery is performed to facilitate gland shielding during radiation therapy for head and neck tumors to circumvent radiation-induced xerostomia. It results in an asymmetric postsurgical appearance of the submandibular and submental spaces. Our purpose was to characterize the morphologic and enhancement characteristics of the transferred submandibular gland and identify potential pitfalls in postoperative radiologic interpretation.

Materials and methods: This retrospective study identified patients with head and neck cancer who had undergone the submandibular gland transfer procedure at our institution. Chart reviews were performed to identify relevant oncologic histories and therapies. CT and MR neck imaging was reviewed to characterize morphologic and enhancement characteristics of the pre- and postoperative submandibular glands, as well as interpretive accuracy.

Results: Eleven patients with oropharyngeal and nasopharyngeal squamous cell carcinomas who underwent submandibular gland transfer were identified. The transferred glands were significantly lengthened in the anteroposterior dimension compared with contralateral glands (P < .001) and displaced anteriorly and inferiorly within the submandibular and submental spaces. Enhancement patterns of the transferred submandibular glands varied, depending on the time of imaging relative to the operation and radiation therapy. Submandibular gland transfer was acknowledged in the postoperative report in 7/11 cases. Errors in interpretation were present in 2/11 reports.

Conclusions: After the submandibular gland transfer procedure, the submandibular and submental spaces lose their symmetric appearances as the transferred submandibular glands become lengthened and located more anteriorly and inferiorly, with variable enhancement characteristics. Familiarity with the postsurgical appearance of the transferred submandibular glands is key to accurate imaging interpretation.

© 2018 by American Journal of Neuroradiology.

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Figures

Fig 1.

Fig 1.

Illustrative schematic demonstrating the key steps in the SMG transfer operation, including mobilization or ligation of the facial artery and vein proximal to the SMG, anterior and inferior translation of the gland into the submental space, and bisection of the mylohyoid muscle to allow repositioning of the submandibular duct and ganglion.,

Fig 2.

Fig 2.

Contrast-enhanced CT images demonstrating the typical asymmetric appearance of the submental and submandibular spaces after SMG transfer. The left transferred SMG (arrows) is elongated and displaced inferiorly and anteriorly into the submental space superficial to the anterior belly of the digastric muscle (_arrowhead_s), resulting in an asymmetric soft-tissue density in the submental space and diminished soft-tissue volume in the submandibular space relative to the contralateral gland (asterisks). Note also edema of surrounding tissues in this patient who was 3 months postchemoradiation with cisplatin and NRG-HN002 (NCT02254278;

ClinicalTrials.gov

) de-escalation protocol at time of imaging.

Fig 3.

Fig 3.

Appearance of SMG (arrows) transferred deep to the anterior belly of the digastric muscle (arrowheads) on axial T2-weighted, fat-suppressed imaging and coronal T1-weighted imaging. The patient was 2 months postchemoradiation with cisplatin and intensity-modulated radiation therapy at imaging.

Fig 4.

Fig 4.

Axial and coronal fat-suppressed postcontrast T1-weighted imaging performed 28 days postoperatively for staging purposes demonstrated platysma enhancement (arrows) adjacent to the transferred SMG. The patient had not yet undergone chemoradiation at imaging.

Fig 5.

Fig 5.

Postoperative asymmetry within the submandibular space results in misinterpretation of the superior aspect of the normal contralateral SMG (arrows) as a parapharyngeal mass (axial T2 fat-suppressed and postcontrast imaging). The patient was 2 months postchemoradiation with cisplatin and intensity-modulated radiation therapy at imaging.

Fig 6.

Fig 6.

PET/CT images demonstrating mildly increased FDG uptake in the left transferred SMG (arrows) compared with the contralateral gland (asterisk) 5 months after SMG transfer surgery and 3 months following conclusion of chemoradiation. These findings are congruent with previously published PET findings in a SMG transfer operation and may reflect relatively preserved function in the transferred gland.

References

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