To improve the outcome in patients with benign diseases of the submandibular gland, we have developed an entirely intraoral technique for excision of the submandibular gland. This procedure is anatomically safe and can be performed with minimal morbidity. We believe the essential surgical steps are as follows: (1) infiltration with Xylocaine plus epinephrine with an adequate waiting period for hemostasis; (2) careful identification of the submandibular duct/lingual nerve relationship; (3) anterior retraction of the mylohyoid muscle to expose the superficial lobe; (4) superiorly directed, extraoral, manipulation of the submandibular gland; and (5) close and blunt dissection to the gland laterally to avoid injury to the facial artery and vein.

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Introduction: Extracorporeal membrane oxygenation (ECMO) is becoming an important therapeutic option for patients with severe acute respiratory distress syndrome (ARDS). Pneumothorax is a known complication of mechanical ventilator strategy in ARDS. Anticoagulation given during ECMO increases the chance of uncontrolled bleeding. We report management of hemopneumothorax in a patient with kyphoscoliosis, hypothyroidism, and acute viral pneumonia in a patient with severe ARDS who was on ECMO support.Case Report: We report a 55-year-old woman, a known case of kyphoscoliosis and primary hypothyroidism received with refractory hypoxemia. The patient was immediately intubated and put on mechanical ventilation. In view of high fraction of inspired oxygen (Fio 2 ) requirement (severe ARDS) on ventilator, prone positioning was done. Due to high positive end-expiratory pressure (PEEP), she developed sight-sided pneumothorax leading to implantable cardioverterdefibrillator (ICD) insertion. Still she was not maintaining peripheral capillary oxygen saturation (Spo 2 ), and chest X-ray (CXR) worsened. She was put on ECMO. During ECMO, she developed bleed from ICD site. Local site adrenaline infiltration was done. Massive blood transfusion was done (13 units in 24 hours). Target activated clotting time (ACT) level was kept on lower side and bleeding stopped. CXR revealed right hemothorax (clots). Till seventh day of ECMO, the patient did not show any improvement, so thoracotomy was done on ECMO and clots were retrieved. Postthoracotomy CXR revealed lung expansion. Following this, the patient had massive bleed for which massive blood transfusion (packed red blood cell [RBC], random donor platelets [RDP], single donor platelets [SDP], cryoprecipitate, fresh frozen plasma [FFP]) was done. On 01/11/17 (eighth day), the patient was weaned off from ECMO. Post ECMO, her Fio 2 requirement was 65%. Computed tomographic (CT) scan of her chest revealed bilateral diffuse ground-glass opacities with septal thickening, and her bleeding stopped. In next 3 days, her Fio 2 requirement was increased so she was started on steroid and diuretics, and antibiotics were escalated. The patient's condition did not improve, and she was discharged against medical advice.Conclusion: Management of hemopneumothorax on ECMO is a very challenging task due to anticoagulation. Massive bleeding needs blood transfusion, targeting low ACT during ECMO. Surgical exploration on ECMO is also challenging, but with careful planning, surgery can be managed well.