Thursday, May 05, 2011

Is Submandibular Gland Transfer a Solution for Xerostomia in Cancer Patients?

The submandibular gland in the submental space. the posterior and inferior borders were outlined with 25-gauge wire to help identify the gland during radiotherapy planning
Photo courtesy of McGill University

For patients suffering from cancer in the mouth or throat, a recent study shows that a treatment called submandibular gland transfer will assist in preventing a radiation-induced condition called xerostomia.

Also known as dry mouth, xerostomia occurs when salivary glands stop working. University of Alberta researcher Jana Rieger likens the feeling of xerostomia to the experience of the after-effects of having surgery and anesthetic - but the feeling is permanent.

While the importance of healthy saliva glands may be an afterthought for some patients when battling cancer, the long-lasting effects create a number of problems for them when they are in remission.

"We need saliva to keep our mouths healthy," said Rieger. "Without saliva, people can lose their teeth, dentures don't fit properly and the ability to swallow and speak is severely altered."

The study conducted by Rieger, a speech language pathologist in the Faculty of Rehabilitation Medicine, looked at functional outcomes - speech changes, swallowing habits and the quality of life of patients with mouth and throat cancers - as they received two different types of treatments prior to and during radiation.

The first group of patients underwent the submandibular gland transfer. This method was pioneered by Hadi Seikaly and Naresh Jha at the University of Alberta in 1999. The transfer involves moving the saliva gland from under the angle of the jaw to under to the chin. Prior to this procedure, the saliva gland was in line for the radiation. Seikaly says, "Most patients, when they are cured from cancer, complain of one major thing: dry mouth."
Here is a 2006 paper (Pdf) that shows some promise for the procedure as well.



Radiation-induced xerostomia is a significant morbidity of radiation therapy in the
management of patients with head and neck cancers. We have recently reported a method of transfer of one submandibular gland to the submental space in a small pilot series of eligible surgical patients.
The submental space was shielded during postoperative radiation therapy. The transferred gland continued to function after the completion of radiation therapy and none of the patients developed xerostomia. The purpose of this article is to present the technique of submandibular gland transfer in detail and to evaluate the postoperative survival and function of the transferred submandibular glands.


Prospective clinical trial.


The submandibular gland was transferred on eligible patients as part of their surgical intervention. The patients were followed clinically, with salivary flow and radioisotope studies.


We performed the surgical transfer of the submandibular salivary gland in 24 of 25 patients placed on the protocol. All the glands survived transfer and functioned well postoperatively as demonstrated on the salivary flow and the radioisotope studies. The surgical transfer was relatively simple and added 45 minutes to the surgical procedure. There were no complications attributed to the submandibular gland transfer.


We have successfully demonstrated that the submandibular gland can be surgically transferred to the submental space with its function preserved. The gland seems to continue functioning even after radiation therapy with the appropriate shielding. This surgical transfer procedure has the potential to change the way we currently manage patients with head and neck cancer.

[PubMed - indexed for MEDLINE]
But, there is a non-surgical approach, as well - the oral drug Salagen (Pilocarpine).
The second group in the study took the oral drug salagen. Rieger says, "Studies have shown in the past that if this drug was taken during radiation, it might protect the cells in the salivary glands."

According to the study findings, both groups had the same results in terms of being able to speak properly but where the main difference was in swallowing. The group taking the drug had more difficulty.

Rieger said, "This group needed to swallow more, and it took a longer time to get food completely out of their mouth and into the esophagus. Because they had trouble eating, they may become nutritionally comprised."

This leads to a host of other problems. Dry mouth causes one to drink large volumes of water, which leads to numerous trips to the bathroom. Difficulty swallowing causes issues with eating food while it's still hot and it takes the patients a long time to complete a meal.

As a result of these problems, Rieger found the quality life for most patients decreased significantly. "People suffering from xerostomia no longer want to go out eat and be in social settings. Consuming water to quench dry mouth means they have difficulty in getting a good night's sleep. Some become depressed and avoid going out." Based on this study, the authors hope to encourage patients to have the submandiublar gland transfer as a preventative treatment for xerostomia prior to radiation for mouth and throat cancers.
Here is a lnk to Dr. Jana Rieger's paper.

Quality of life is very important for cancer patients. If this surgical procedure, can restore salivary flow, then it is well worth the discomfort of surgery.

Functional assessment outcomes are essential for cancer patients as they weigh their treatment options.

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