So, hello everybody. I'm Doctor Stefanos Slavakis from Greece. I'm the head of Veterinary referral clinic of CR Veterinary Hospital, and I also work in that referral Surgery centre in Thessaloniki as a referral with a surgeon.
In the next hour, we will talk. About a favourite topic of mine, thought about mucoceals and I will try to give you some tips. And some tricks on how you can address them nicely.
We're gonna overview what we're gonna talk about in the next hour, anatomy, diagnosis of mucoces, surgical options. The post-operative management, we're gonna talk about complications, a few things about prognosis, and finally, we'll wrap up with some tips and tricks regarding salivary mucos cells. What is a salivary mucoil?
It's a collection of saliva that has leaked from a damaged salivary gland or salivary duct. That simple. Keep in mind that salivary mucos are not cysts.
Cysts are cavities lined with epithelium. Salivary mucoceles are lined by granulation tissue which is produced secondary to inflammation caused by the fish saliva in the tissues, and it prevents saliva from migrating further. The swelling may be painful initially, but the animals are usually asymptomatic.
The sublingual salivary gland is one most commonly involved with salivary mucous cells. Some facts about the cyber glands and mucos cells. What we often see is cervical mucoils and sublingual mucoceles, sometimes they're together.
Rarely we can, we see neoplasia, abscess, or cellulis when it comes to salivary glands. The aetiology of the mucosis is generally unknown, maybe. Due to trauma or a foreign body.
Their location that can be either cervical, sublingual, pharyngeal, or less frequently psychromatic. Species that are affected, dogs, mainly, and less frequently cats. Canine breeds more commonly affected are poodles, German shepherds, and dasmunds.
Now, when and why do we need to remove? Surgically, a salivary gland. Due to mucoil or due to neuroplasia, mucoces are generally seen in young adult dogs.
Males are most commonly presented, usually 2 to 4 years old. For this kind of mucoussis sublingual salvagland defect is found in almost 90% of these cases. Paroid and zygomatic mucoceles are less frequently seen.
Neoplasia comes more or less more often with parted and zygomatic fibre glands. Neoplasia can be either benign adenoma or lymphoma or malignant like adenocarcinomas, squamous cell carcinomas or faulty sarcomas. A few things about anatomy of the salivary glands.
There are 4 pairs of salivary glands, the mandibular, the sublingual gland, the parotid gland, and the zygomatic gland. The sublingual gland has proportions, the monosomatic and the polysomatic, and they end lateral to the tongue in your cavity near the fangulum. Clinical findings depends on the location of the muco cell.
For cervical muco cells, we generally have a soft fluctuent non-painful mass which is gradually developing. For sublingual muco cells, we generally have animals that have salivation. The saliva is Blood tinged or maybe not, and they also have dysphagia.
For pharyngeal mucoceles, we have dysphagia or and or spot or distress, and these are some cases that may be presented to us as an emergency. For zygomatic muco cells, peral fascial swelling and pain is usually seen along with ophthalmus and optic neuropathy. Regarding diagnosis, diagnosis is based on history, clinical findings, and parenthesis.
From history, we can understand that clinical signs depends on the location of the mucosil. Remember regarding the clinical findings that mucosils are soft, clot, and painless. Tumours and abscesses are for.
Diagnosis is confirmed by procentesis. Try to be aseptic with your technique, and when you do that, you will find generally a mucoid fluid in the low cell count could be clear, yellow, or blood tinged or in chronic cases, you may even aspirate to alysts. First people of the day.
Conservative treatment. Of salary muco cells is rarely successful. Your definite treatment is a surgical one.
When it comes to cervical muco cells, the, the problem we have from time to time is to determine the affected side. And here are some tips on how you can do that. First of all, if we have a unilateral sublingual mucosil or also called granula or a pharyngeal mucocele, then we know that at the same time if there is a cervical mucocele this originate from the same side.
If we still cannot decide. Which side is the affected one. Apply some digital pressure on the cervical mucocele and you will probably see a rangula formed as shown in the video here.
You can see the, the pressure that's applied and the rula of this. The dog has in his left side. When we press the right side, there's no rangular.
Formed Another thing we can do is to place the patient in a recumbency and use the gravity to help us differentiate the affected side as shown in the small picture. You see this huge Cervical cello in this dog, which, as you can probably understand, comes from the sublingual gland of the left side. And if we still cannot determine what's going on, then we can go to surgery and perform a stab incisions and mucoil and palpate the aluminium of the mucoil.
And if that happens, the unaffected side is broad and smooth, while the affected side has a track toward the liage point. Useful tips. Diagnostic imaging is that useful?
Well, it can be useful in cases of cellulose, foreign bodies, or neoplasia. A zone in the tube. Here, here is the mandibular gland.
This is an adenocarcinoma. And you can see another one here, the same case. Differential diagnosis, theloinitiss, cellular neoplasia, yoids, cervical abscesses, foreign bodies, hematoma, cystic or neoplastic lymph nodes.
These are all conditions that we must differentiate from a salivary mucosille. Regarding management, I've already told you, is surgical, and surgical management means full excision of the affected salivary glands plus drainage. So in the question of how I treat cervical mucousy, the answer is by removing the mandibular and sublingual sul gland.
Also providing res the muco cell and when people ask, OK, if I cannot determine the size, can I remove The glands from both sides and do bilateral. Well, yes, you can go on, you can do that. It's OK.
There are 2 more pairs of thyroid glands that can produce saliva, so no problem. Let's see the anatomy again. You can see here the mandibular and the sublingual glands how closely they are together.
They serve the same capsule and they go beneath the digastricu muscle ending. At the oral cavity lateral to the trunk, lateral to the final. Surgical approach.
Well, I do know that most of you know that we can approach the salivary mucoses by removing the mandibular and sublingual gland either with a lateral or a ventral approach. So let me tell you some things about the lateral approach first. This is a case back from 2005.
You can see a German shepherd dog, a 7 year old German shepherd dog with his cervical muco cell, you see the local dermatitis. From the saliva that is leaking and from lateral, you can see the Swelling at this point in the mid cervical area. When we place our patient in the dorsal recumbency, you can easily, very easily understand that the affected side is the right one.
We provided drainage. And we went from a la coach as the boss and Johnson are describing with the surgery, . These are our landmarks.
The mandibura gland. It's fine just in front of the defocation of the jugular vein to the maxillary and the lingo fascial vein. So you can either do one of those three initial incisions if you want to.
Locate The gland. So this is my preference. Skin incisions, subcutaneous tissues, and just after the sub-Q, we will find the platysma muscle, the only muscle that we need to cut.
With our seizures or with our coy. You can see here the mandibular gland. And this capsule, where it's when you go around the capsule 360, you will see the mandibular gland.
You would grasp the grant with the anaesthesia forceps here that makes the manipulation much easier. We got 360 around until we find the blood supply to the man glands. You can either cauterise or.
Do your ligatures with it, no problems what you prefer and then you Keep digging and go. Retracting The mandibular and sublingual gland. Caudally until the the gas muscle you go beneath the muscle and after that, you click the more with the ligature and you're done.
This is our, our patient. A few days after surgery on recovery. Vener approach People say it's more difficult.
I say maybe it's more accurate. Ventual approach is, being performed like Hofer and cables and Liowitz described back in 1975 and 1989. You can see the anatomy here.
We are cutting our incision line is the blue one is shown here. And after that, after cutting the skin and the subcutaneous tissues and platysma muscle, we find the capsule beneath the capsule with this mandibular gland, sublingual gland is so much better here and then we are passing a hemostat beneath the digascu muscle. We grasp the duct of the sublingual and mandibular gland which we cut the glands and we breeding or a mosquito was immediately.
As shown here and you will see here the mylovius muscle that we need to cut a little bit in order to follow the ducts. Rustally to the oral cavity. So here you see here the malo this muscle has been cut and reflected.
And this is the duct that we can follow until we find this. Nerve here, the lingual nerve, and that is where we can put our clip or our suture perform a ligature and cut. Or pull In order to Put all these plants and ducts away and conclude the surgery.
Here we are in a, in a case. You see here are patient even recumbency. We have Use a sterile pen for our landmarks.
This is the incision line. You can see here the, let's see from the lateral point of view, much easier, the external jugular vein, the lingofascial vein, the maxillary vein. And our incision line.
And this is the mandible ramus, which is a good landmark for us. This is how we can say this. On the top, the gascu muscle, the sublingual salivary gland, the mandibular salivary gland.
We pass our hemosta beneath the gascus muscle. We are grasping the duct. Of the sublingual gland and mandibular gland, and then we're reflecting them rostromedly.
Same thing with this case. Here you can probably see how superior the exposure of the gland is and how nicely we can perform our dissection. This is our patient At the end of surgery, you see here the Penrose has been placed to provide drainage to the cervical mucocele.
Here is our patient. 4 or 5 days, I think, if I recall postoperatively, of course, the swelling is still there. It needs about 5 to 10 days for the swelling to be completely resolved.
This is another interesting case, a huge cervical celo cell. And this like poodle and let's see a small video of how it was addressed. It was impossible to find the mandiburulandde the series was too large, so we Go The cellosil will provide drainage to the cervical.
Mucoy We opened it up and we found The mandibular gland as shown here with our seizures. We are going 360 around. The glands Here is the mandibular and sublingual gland there duct.
You will see now. The hemote going beneath the vasculous muscle here. In this case, I've elected to use some suture.
To make my life kind of easier. And the video looks too big, but believe me it was much smaller than surgery. It's a 4 kg patient.
So when we do have a suture tag at the moment, we are cutting. The sublingual and ventricular. Silver glands with our scalpel and we're taking the tissue tag.
And reflected beneath the gascu's muscle rostromedly. You see how nicely this is performed. And the suture help us manipulate.
The doctor Much easier We can continue our dissection protally to the mylohyidus muscle and at that point, you can Grasp the duct with your mosquito. Wrap it around the mosquito and pull it back. Very, very, very nice.
You see the how it comes. Nicely awake. Lavaz, the surgical site with saline, put a Penrose drain, and then you cut.
Then you suture what you have already cut, meaning the platsal muscles, subcutaneous tissues, and skin. This Just in case, I prefer to use the enrose grain. You can also use an active drain like a Jackson Pratt, no problem, it's your preference.
Synthetic monofilament absorbable sutures like as PDS or monocule are super fine. In the skin futures, whatever you want. And that's it.
For sublingual, mucocellular ranullo, a surgical treatment, of course, is one more time anddibular sublingual gland excision along with muscularization. And this is a nice case of sublingual cell cell in a cat. You have all this information in your notes.
Also, you see the CT scan here, how nicely this cell cell is seen. And you can see here are colleagues removing the mandibular gland, the sublingual gland, the monosomatic part of the sublingual gland, and the polysomatic part of the sublingual gland. And after doing that, the this masculization of the sublingual cellocemization means that we're removing an elliptical part of the sublingual mucocele and we are saturing the rest, the remaining part, in the, in the oral cavity.
And this is the small. Hole that remains, remains back so the saliva can still be running from that point. When it comes to pharyngeal mucoceles.
It's very easy to understand why these cases from time to time may be presented as an emergency, right? Multipleization and salivary gland excision, is the treatment of choice also in these cases. Here is a 5 year old big dog.
You see here the pharyngeal yellow cell and you can see the multipleization at this point, during it is provided and the remaining tissue is situd to the nearby tissue of the oral cavity with mono. Regarding post-operative management now. Antimicrobials can be prescribed for.
5 days 7 days or maybe not depending on what you're sent in surgery, provide drainage, that's very important. Drainage is adequate if if it is provided for 3 to 5 days, generally we do, use some light bandages to protect our, drains. As I already told you, drains can be either passive or active.
If you use passive drains, if you use en roses, keep in mind that the saliva is very irritant to the skin, so it's very wise if you use some water-soluble lubricant like TY jelly, beneath the exit point of your cranrose in order to, not have dermatitis, local dermatitis from, saliva in the next days. For active veins, definitely this is not a problem. Pain management, of course.
Usually, NSAIDs is all that you need to prescribe. And when it comes to sublingual or pharyngeal mucocele, the extra thing that we do postoperatively is to provide to our patients soft food and to rinse their mouth with water after food intake just to be certain that the oral cavity is clean of food, so no infection, . Will be present and are healing of the traumas that we have in the oral cavity will be uneventful.
Complications, 3 other major complications that may be thin, seroma, infection, and recurrence. It's very easy to understand why seroma can be one of the complications to the dead space. So, as one of my, teachers said, Leave that space, seroma in place.
Try not to leave that space behind when you leave from this kind of surgeries from salivary mucosal surgery. Another reason why seroma can be, formed is because your muscularization site is too small. So take care not to leave that space, and your musculization site take care to be, big enough.
Infection, infection and surgery, that means, yeah, that we were not, aseptic during our operation, keep it, try to be, good surgeons by being very cautious with your aseptic technique. But the thing that we must, we mostly see, as a complication when it comes to salivary muco cells is recurrence and why is this recurrence happening? For three main reasons.
Reason number one, maybe we perform surgery on the wrong side. Or we had an incomplete gland excision and that is usually the, the thing with the sublingual gland. We usually find remnants of the sublingual gland.
When we go back for revision surgery, or even worse, we had the wrong tissue excision, that means that we, excise, for example, a regional lymph node instead of a salivary gland. This is a case of a German shepherd dog that was treated for, initially for cervical mucocele, but Unfortunately, we had a recurrence and you can see here the remnants of the salver glands that were removed during the second surgery. One more case here my good friend, Doctor Gima Jos Papazoglu, this is a cervical mucocele here and, at this point, Gleema was selected to go through the oral cavity in order you can see his incision lateral to the town in order to remove this.
Remnant of the Sublingual gland and duct. You can see his final suture here at the later of the tongue. So oral approach is also an option when you want to remove remnants of the sublingual duct.
Prognosis, well, prognosis is excellent if excision is complete. Remember that. Excellent prognosis if excision is complete with drainage only without excising the salivary glands that are involved, the recurrence in the literature is up to 42%.
It's a big number. And when it comes to neoplasia, survival can be more than one year in many cases. We've already talked in the very beginning about this neoplasia case.
This was a mandibular gland adenocarcinoma, as you can see here, this enlarged Mandybura gland this CT scan. This is another case. Involving the Madeburg land also.
You can see the close proximity with the common artery, the external carotid artery, and the internal carotid artery. We finally managed to remove the gland without causing any damage to the carotid arteries, and this is our patient few days. After surgery and suture removal, histopathology came back as a squamous cell carcinoma, and our patient, finally died eight months after initial surgery.
So to wrap up, let's say some tips and some tricks that we have already said, but let's summarise them in a In a way at the moment, concurrent sublingual and cervical mucocele originate from the side where the sublingual mucocele is located. So you can't be wrong, right? Why it out.
Put your patient in the incumbency. This will help you identify the origin of the mucocele. If this doesn't work, apply digital pressure.
Digital pressure in the cervical mucocele may produce arannula, OK? If this doesn't work, you can do your stab incision in the mucousy during surgery and find where is the smooth side. And on the other side, you will find the path to the luggage and the affected salivary gland.
If nothing of these works, the only thing that remains to you is to ask the owners, which saw the first not noticed the swelling. It will be helpful from time to time. Ventral or lateral approach?
Well, both are fine. It's just what you prefer to do. Go on, do it.
I do both, but I prefer ventral approach because the exposure, as I've already told you, is much better. And one more thing, with ventral approach, you can do at the same time a bilateral ilulectomy without the need to reposition your patient. Lateral approach may make your life more difficult if a most rosal excision has to be performed.
These are some nice papers you can Find in the literature, all these are included in your notes, where you can see how tunnelling under the muscle increases the exposure and completeness of the excision. This is, these are more or less to make you see which one of the two, approaches lateral or ventral you can choose. I can tell you again, both are fine.
I prefer ventral if I ask. And Finally, some small steps, use a sterile marker pen for your anatomical landmarks. It's pretty much OK.
It will help you to do a first initial, your initial cut to be the right one. And this is very helpful when you do surgery. Have a very nice initial look at.
If your first cut is wrong, then the surgery will be a mess. Use a pad or a towel under the neck of your patient in order to fix his neck. In an extended position that will make your life much easier.
If you have an assistant, it's even better, he will make or she will make your life easier. It's not essential though. Coy.
Will make you sweat less. For those of you who use cutlery, you know that, although it's not essential. Drainage, I already told you passive or active drains, both are fine.
Remember, if you use Penrose drains to place some stirring, sterile lubricating jelly below the exit point to prevent local dermatitis because saliva is irritant to the skin. Remember to lavas the surgical site before closure. Try using synthetic absorbable monofilament sutures.
When it comes to suturing, the only tissues you need to suture during salivary mucosal surgery and especially when it comes to removal of the mandibular sublingual glands is Platysma muscle, subcutaneous tissue, and skin. And if you have a recurrence, don't forget that you can go. Through the mouth and the oral cavity performing an oral approach.
These are your references, many papers you can read in order to have a better understanding of what's going on with salivary mucosils, great papers from great colleagues. That's it. I hope you enjoyed it.
If you have any questions, please don't hesitate to send me an email. I'll be more than happy to answer. Many thanks to Web Novet for the invitation.
Have fun.