Platysma muscle-cervical fascia-sternocleidomastoid muscle (PCS) flap for parotidectomy

BACKGROUND

Parotidectomy is useful in the treatment of benign and malignant neoplasms of the parotid gland, but often leads to sequelae of facial deformity and Frey's syndrome. This paper presents a retrospective review of parotidectomy results in 21 consecutive patients treated with either traditional techniques or with the rotation and advancement of combined platysma muscle-cervical fascia-sternocleidomastoid flap (PCS).

METHODS

The surgical procedures utilized for removal and reconstruction are described. Information on appearance and function was obtained by analysis of hospital and office records and telephone questionnaire for patients with and without the flap.

RESULTS

Of the 21 patients eligible for this study, only 9 of 10 patients with the PCS flap and 10 of 11 patients without the flap provided sufficient data for analysis. In the flap group all 9 patients either noted a mild fullness on the operated side or no difference between sides. In the nonflap group, 4 patients felt they had a moderate depression, 2 patients noted a mild depression, and 4 patients noted no difference between sides. Frey's syndrome was classified as mild in 2 patients in the PCS group, whereas in the nonflap group, 4 patients thought it was mild and 1, severe. Complications were rare in either group.

CONCLUSION

The PCS flap prevents deformity and contributes to patient satisfaction following parotidectomy. The flap helps to prevent Frey's syndrome and is not associated with an increase in postoperative complications. The flap is recommended following removal of nonrecurrent or low-grade malignant parotid tumors.

A comparison of one hundred and fifty consecutive parotidectomies for tumours and inflammatory disease

The demographic profile and complications are compared and contrasted for 150 consecutive parotidectomies. All patients were under the care of one surgeon (JDL) over a twenty-year period (1977-1997). The case records and contemporaneous database were analysed retrospectively. 111 (74%) procedures were performed for tumours and 39 (26%) for inflammatory disease. The incidence of unexpected permanent facial nerve palsy was 1.8% in the tumour group and zero in the inflammatory group. The overall unexpected palsy rate was 1.3%. Transient paralysis was more common in the inflammatory group than the tumour group (61.5% compared with 33.3%, P<0.02) and was more likely to be panfacial (48.7% compared with 17.1%, P<0.0002). The overall incidence of Frey's syndrome was less than 20% and both salivary fistulae and sialocoeles were infrequent.

Gustatory sweating: clinical implications and etiologic aspects

PURPOSE

It was the aim of this study to provide detailed general information on the clinical picture of different kinds of gustatory sweating, including reevaluation of a series of patients who underwent parotidectomy, removal of the submandibular gland, or neck dissection.

PATIENTS AND METHODS

This study summarizes the statements of 548 patients questioned about the occurrence of gustatory sweating after parotidectomy (n = 296), extirpation of the submandibular gland (n = 79), and neck dissection (n = 173).

RESULTS

After parotidectomy, 45% of the patients had noticed gustatory sweating. In most of them (70%), the symptoms began within 6 months after surgery. Gustatory sweating developed in only one patient with submandibular extirpation (1.5%), and not at all after neck dissection. Most patients (52%) reported that the symptoms occurred independent of the kind of food ingested. These results show that the "masticatory component" is an important trigger for Frey's syndrome. Application of Minor's test localized gustatory sweating mainly in the region of previous parotid lobe removal, but also in other areas deriving their sensory supply from the auriculotemporal, greater auricular, and lesser occipital nerves. The size of the area affected by the sweating was similar after lateral and total parotidectomy. When evaluating clinical symptoms, subjective assessment by the patients seemed to play a major role. After submandibular extirpation and neck dissection, some patients reported gustatory sweating that was not verified by Minor's test.

CONCLUSION

There is general agreement that the cause of gustatory sweating is sympathetic or parasympathetic innervation of previously denervated sweat glands, initiated by gustatory triggers. The location of the "erroneous innervation" depends on the type of lesion. In cases after parotidectomy, misdirected parasympathetic regeneration is the model integrating all known factors into a rational concept. For didactic and systematic-pragmatic reasons, a clinically oriented classification of gustatory sweating (types I to III) seems to be useful.

Diabetic gustatory sweating successfully treated with topical glycopyrrolate: report of a case and review of the literature

BACKGROUND

Gustatory sweating is a more common manifestation of diabetes mellitus than is appreciated. It is a distressing problem that has been difficult to treat safely.

METHODS

Daily topical application of glycopyrrolate roll-on lotion was offered as an alternative to oral anticholinergic agents to an 87-year-old woman with long-standing type 2 diabetes mellitus who complained of profuse sweating after eating.

RESULTS

Gustatory sweating was relieved by application of glycopyrrolate and reappeared when the glycopyrrolate was briefly withdrawn to confirm its therapeutic effect.

CONCLUSION

For moderate to severe symptoms of diabetic gustatory sweating, topical application of glycopyrrolate is safe, effective, well tolerated, and convenient.

Gustatory otalgia and wet ear syndrome: a possible cross-innervation after ear surgery

HYPOTHESIS

The chorda tympani and Arnold's nerves have close approximation to each other and their cross-innervation is possible after ear surgery.

STUDY DESIGN

A retrospective study was performed with a temporal bone pathology case and two clinical cases as representatives of such a possibility. Patients had severe otalgia and wet ear during gustatory stimulation.

METHODS

A temporal bone pathology case was studied under a light microscope. Earache and/or wet ear were provoked during gustatory stimulation. Wet ear was tested with iodine-starch reaction after the subject tasted lemon juice.

RESULTS

The temporal bone specimen has clusters of regenerated fibers in the tympanic cavity in the area of the chorda tympani and Arnold's nerves, suggesting a possibility of mixing. There are regenerated fibers in the iter chordae anterius, showing successful bridging of the chorda tympani nerves across a long gap. Detachment of the skin over the operated mastoid bowl obscured signs in one clinical case. Another clinical case of gustatory wet ear showed objective evidence of cross-innervation with iodine-starch reaction.

CONCLUSION

The detachment procedure and iodine-starch reaction were the proofs that the signs were related to regenerated fibers. This is the first report of gustatory otalgia and wet ear after ear surgery.

Botulinum toxoid in the management of gustatory sweating (Frey's syndrome) after superficial parotidectomy

Botulinum toxin has been successfully used to treat Frey's syndrome occurring in a 31-year-old patient following superficial parotidectomy for pleomorphic adenoma. An initial injection of 7.5 U (0.3 ml over 6 cm2 of cheek) resulted in 3 months' resolution of gustatory sweating and flushing and a second injection 12 months' symptomatic improvement. The symptoms recurred after further facial surgery.

Frey's syndrome after carotid endarterectomy

Frey's syndrome after carotid endarterectomy (CEA) is due to iatrogenic injury to the auriculotemporal nerve and has not been previously reported. One month after uncomplicated CEA, our patient noted an erythematous flush and copious drainage of clear fluid from the superior portion of his neck wound whenever he ate, or smelled or thought of food. These symptoms lasted for 2 months and eventually resolved without intervention. The cause and treatment of Frey's syndrome is also described.

Parotidectomy: a plastic approach

Three disadvantages are frequent after parotidectomy: a scar affecting the neck, a deep hollow between the sternocleidomastoid muscle and the mandible (the larger the resection is, the deeper is the hollow), and a sweat secretion. These disadvantages can be prevented or reduced by using four simple procedures: (1) using a facelift incision; (2) using a very simple and original "trick," by displacing outward the posterior belly of the digastric muscle; (3) using a flap with an upper pedicle taken from the sternocleidomastoid muscle; and (4) using a double free graft, taken from the superficial and deep temporal fascias. These two grafts lay down on the net constituted by the preceding flaps. They line the skin, thus blocking the wrong innervation.

Parotid swellings: report of 110 consecutive cases

Parotid swellings are uncommon. Over a twelve-year period, 110 cases of parotid swellings were treated at the Department of Plastic Surgery, Hospital Kuala Lumpur, of which 97 cases were histologically proven to be parotid tumours. 75% of these tumours were benign tumours, and 80% of the benign tumours were pleomorphic adenomas. Among the malignant tumours, 6 cases were adenoid cystic carcinoma and 5 were carcinoma ex-pleomorphic adenoma. There were equal number of male to female patients, with an age range of 14 to 83 years. There is a positive correlation between the final histological diagnosis and FNAC results in 74% of cases. Surgical treatment of choice for benign parotid tumours was near-total parotidectomy whilst for malignant tumours was total radical parotidectomy with sural nerve graft.

Frey's syndrome following submandibular gland excision: an unusual postoperative complication

Gustatory sweating and flushing, or Frey's syndrome, is a fairly common complication following surgery or injury to the parotid gland and is thought to be caused by aberrant nerve regeneration. A similar condition has been reported in the literature following surgery to the submandibular region. Since this was first described in 1934, only 7 subsequent cases of submandibular sweating and flushing have been reported. We present a case of a 52-year-old female who underwent excision of the left submandibular gland as a result of chronic sialadenitis. Twelve months following surgery, symptoms indicative of Frey's syndrome were experienced in the operative region. A review of the aetiology and treatment of the condition is described.

Atypical Frey syndrome as a complication of Obwegeser osteotomy

A patient with Frey syndrome on the left cheek area as a complication of an Obwegeser osteotomy is reported. Flushing, sweating of skin, and hypoesthesia of buccal mucosae were present 6 months after surgery. An injury to the auriculotemporal nerve during desperiostization of the posterior border of the mandibular ramus is believed to be the principal cause. The physiopathologic mechanism is thought to occur in relation to aberrant regeneration of the postganglionic secretomotor parasympathetic nerve fibers carried in this nerve. These regenerated fibers erroneously reach the sweat glands of the cheek skin through anastomosis with the buccal nerve and temporofacial ramus of the facial nerve. Direct injury of the buccal nerve may be another cause, because of its close anatomic course with the external pterygoid muscle and the mandibular ramus. An extensive literature review revealed no cases of this syndrome as a complication of Obwegeser osteotomy.

Recurrent benign parotid tumours: the lesson not learnt yet?

BACKGROUND

To study the behaviour of recurrent benign parotid tumours, recurrence characteristics and problems faced with the removal of these lesions.

METHODS

We reviewed the charts of the work of a single surgeon between 1971 and 1996.

RESULTS

There were 24 patients (13 women, 11 men) with a mean age of 44 years at re-operation. Mean follow-up period was 10 years (range 1-22 years). There were 21 recurrent pleomorphic adenomas, two monomorphic adenomas and one patient with recurrent oncocytoma. Nine patients had solitary recurrence with a mean size of 14 mm, 15 patients had multiple recurrences with a mean size of 8 mm. There was malignant transformation of a previously benign lump in one patient. Three patients presented with a second or third recurrence. Overall facial nerve paralysis was 53% (38% temporary and 15% permanent). Frey's syndrome occurred in four patients (17%).

CONCLUSIONS

Recurrent benign parotid tumours are uncommon if superficial parotidectomy (SP) is the performed initially; recurrence rates are between 0-4%. The recurrences are usually slow growing and require lengthy follow-up. Pre-operative diagnosis of a lump in the region of previous excision is useful in treatment planning. Malignant transformation in previous benign lump should be considered and fine needle aspiration biopsy may help in diagnosis. Facial nerve injury is more likely if the tumour is deep, in multiple sites or involves extensive scar tissue. Radiotherapy is controversial, it should be considered if there has been tumour spillage following re-operation.

Frey's syndrome without hyperhidrosis

Images

Local excision of the parotid gland in the treatment of Warthin's tumour

The results of local excision of Warthin's tumour in the parotid gland (n = 61) (resection of the tumour together with surrounding normal gland and associated lymph nodes) were compared with those of superficial parotidectomy (n = 88) for incidence of recurrence, duration of operation, and degree of facial deformity. A subgroup of patients in each group were tested for gustatory sweating (iodine starch test) and parotid function (quantitative scintigraphy). Local excision had the following advantages over superficial parotidectomy: shorter operating time, less risk of facial nerve damage, less facial deformity, lower incidence of Frey's syndrome, and better preservation of the function of the parotid gland.

[Surgery in benign parotid tumors: individually adapted or standardized radical interventions?]

BACKGROUND

Several authors demand emphatically that the minimal operative procedure in benign parotid gland tumors has to be a superficial parotidectomy.

MATERIAL

Of a consecutive series of 372 patients with benign parotid tumors treated in our department between 1973-1996 81% of the patients could be followed up 1-24 years. in 10.9% a total parotidectomy was performed, in 16% a lateral parotidectomy and in 73.1% a simple extirpation of the tumor (often taking away a small margin of surrounding parotid parenchyma). The operating microscope and microsurgical techniques were used in all of these operations.

RESULTS

Of all the followed-up patients 2.3% developed a recurrence. There were no recurrences of cystadenolymphomas or of rare types of adenomas. Recurrences of primary treated pleomorphic adenomas occurred in 3.0%. In recurrent pleomorphic adenomas a further recurrence could be seen in 7.4% of the cases. The over-all incidence of permanent facial nerve weakness was 2.1%: 0.7% after extirpation, 3.3% after lateral parotidectomy and 9.7% after total parotidectomy. we observed in 6.3% a gustatory sweating.

CONCLUSION

Our data prove that with simple extirpation similar results compared to lateral parotidectomy can be achieved concerning recurrence, function of the facial nerve and the Frey's syndrome. We suggest a surgical management adapted to the extent, the size and the location of the parotid gland tumors. In our opinion lateral or total parotidectomy should be reserved for tumors of larger amount or deep located tumors.

Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Frey's syndrome)

Several therapeutic approaches exist to treat gustatory sweating (Frey's syndrome) following parotidectomy. Because of the lack of effective treatment, a new therapeutic modality using botulinum toxin injections was presented previously by our group. The duration of the demonstrated positive effect was essentially unknown so far. Based on our experiences using this technique since December 1993, the purpose of this clinical investigation was to make an up-to-date report and demonstrate the duration of effect of BOTOX injections in patients with severe gustatory sweating. Nineteen patients with severe gustatory sweating have been treated with BOTOX by intracutaneous injections into the affected skin areas. The maximal follow-up time was 33 months. The results were obtained by interviews and controls using Minor's starch iodine test. In all treated cases (n = 19 patients, 22 treated sides) gustatory sweating ceased completely within 2 days. Side effects were absent. In 12 patients gustatory sweating reappeared. The mean duration of effect was 17.3 months (subjective personal communication of 18 patients). Findings show that intracutaneous injection of BOTOX is a highly effective, safe, and minimally invasive treatment of Frey's syndrome with long-lasting therapeutic effect.

[Parotid gland tumor histopathologic picture and treatment]

The records of 41 patients with tumours of the parotid gland treated in ORL Clinic in Białystok from 1990-1995. Were retrospectively reviewed. Malignant tumours constituted 11.5% of all tumours. The most common benign tumour was pleomorphic adenoma. Superficial or total parotidectomy was used as the method of treatment. The incidence of facial nerve dysfunction was 4.87%. Only 4.87% of patients developed Frey's syndrome.

Recurrent pleomorphic adenomas of the parotid gland: clinical evaluation and long-term follow-up

We report 94 patients with recurrent pleomorphic adenomas of the parotid gland who were referred to our clinics after operations elsewhere. In 78 patients (83%) enucleation was the surgical technique used to remove the tumour. Patients with more than one recurrence were significantly younger than patients who had only one. Many recurrent adenomas (44%) were multifocal. In 20 (21%) further recurrences became obvious after we had operated on them. The mean time interval before recurrence ranged from 7.3 to 10.1 years. Twenty patients (14%) had persistent motor disorders of the facial nerve after operation for recurrence (n = 143). Twenty eight of the 84 patients from whom follow-up data could be obtained developed Frey's syndrome (33%). Our data support the importance of an adequate initial operation to avoid recurrences of pleomorphic adenomas in the parotid gland.

[Surgical treatment of pleomorphic adenoma of the parotid gland. Apropos of 192 cases]

Tumors of the salivary glands are exceptional, representing approximately 2% of head and neck tumors. The parotid gland is most often involved, at a frequency reaching 80%. Histology examination generally shows a pleomorphous adenoma. The choice of a surgical technique best adapted to curative treatment depends on the type of tumor and is widely debated. Our management strategy is based on simultaneous histology examination and superficial parotidectomy. Several pre and intra-operative factors determine the need for resection. We verified our strategy with a retrospective study.

Botulinum toxin type A for Frey's syndrome: a preliminary prospective study

Fourteen patients with severe Frey's syndrome (occurring after conservative parotidectomy) managed with intracutaneous injection of botulinum toxin type A were prospectively evaluated. Results were analyzed for effectiveness, complications, and adverse effects. Complications were not encountered. The only adverse effect noted was a temporary and slight partial paresis of the upper lip of 3 months' duration in 2 patients. Permanent paresis was not encountered. Frey's syndrome was always controlled within 2 days following the intracutaneous injection of botulinum toxin A. Frey's syndrome recurrence was not encountered with a follow-up duration that varied from 3 to 9 months (mean follow-up 7 months). This preliminary report confirmed that in patients who have Frey's syndrome after conservative parotidectomy, the intracutaneous injection of botulinum toxin is a valuable treatment option that should be further investigated.

Frey's syndrome after parotidectomy: a retrospective and prospective analysis

Gustatory sweating is a well-known sequela after parotid surgery. In a retrospective and prospective study of patients undergoing parotid surgery, the onset, time course, extent, and treatment modalities of Frey's syndrome were analyzed. Twenty-two percent of the patients evaluated by questionnaires and 43% of the patients followed prospectively within 1 year were found to be symptomatic. Although the Minor starch-iodine test was positive in 38% of patients at 3 months, none of these patients experienced symptoms. Up to 12 months after surgery the rate of patients who tested positive increased to 96% and the total area of sweating expanded to a mean value of 18 cm2. Whereas most of the patients are not markedly disturbed, few patients (5% to 10%) suffer from severe gustatory sweating. These patients present a therapeutic challenge.

Localized facial flushing in infancy. Auriculotemporal nerve (Frey) syndrome

BACKGROUND

Patients with auriculotemporal nerve syndrome (Frey syndrome) have facial flushing, sweating, or both localized to the distribution of the auriculotemporal nerve that occurs in response to gustatory stimuli. In adults, the syndrome usually results from surgical injury or trauma to the parotid gland. The condition is rare in infants, but usually manifests during infancy with the introduction of solid food, thus leading to the misdiagnosis of food allergy by physicians unfamiliar with the syndrome.

OBSERVATIONS

We describe 8 children with auriculotemporal nerve syndrome who manifested with flushing only. The reaction was erroneously attributed to food allergy in most cases. Six of the 8 patients were delivered with forceps assistance. The remaining 2 patients, with disease onset during the first 3 months of life, had bilateral involvement without known trauma.

CONCLUSIONS

Auriculotemporal nerve syndrome may manifest during infancy as flushing with eating food. In contrast to the syndrome in adults, gustatory sweating is rarely associated. The known use of forceps to assist in the delivery of at least 14 of the 28 previously reported pediatric cases and in 6 of our 8 patients suggests that trauma to the parotid region may be responsible for the condition in most infants, as it is in adults. Auriculotemporal nerve syndrome in infancy should be recognized as a benign condition that often resolves spontaneously. Treatment is ineffective and unnecessary.