Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis

Long-term follow-up and prognostic analysis of parotid tumors in children and adolescents

Objectives

The objective of this study is to summarize the clinical characteristics, treatment, and prognosis of parotid tumors in children and adolescents.

Methods

Fifty-three children and adolescents diagnosed with parotid gland tumors were included. Survival was evaluated using the Kaplan-Meier method. Log-rank test and multivariate analysis were used to analyze the association between clinical factors and recurrence.

Results

Of the 53 patients, 30 cases were benign and 23 cases were malignant. All patients underwent surgery. Patients with malignant tumors with high-risk factors received radiotherapy or chemotherapy. The median follow-up time was 61 months. Of these, 1 patient with benign tumor and 5 patients with malignant tumors recurred. Of the patients with malignant tumors, 2 developed distant metastases and 2 died. The 5-year overall survival (OS) and 5-year locoregional recurrence-free survival (LRFS) rates for benign tumors were 100.0% and 92.9%, respectively, whereas the 5-year OS and 5-year LRFS rates for malignant tumors were 94.4% and 72.5%, respectively. The log-rank univariate test showed that tumor size >3.5 cm (p = .056), distant metastasis (p = .056), and stage III and IV (p = .032) were associated with recurrence. However, multivariate analysis did not show the above factors to be independent prognostic factors for LRFS.

Conclusion

Surgery for benign tumors depends on the location and size. Surgery for malignant parotid tumors depends mainly on the stage, grade, pathological type, and recurrence. Prophylactic lymph node dissection is required for high-grade tumors. Radiotherapy or chemotherapy for children needs more research. Both benign and malignant tumors have high survival rates after active treatment.

Level of evidence

Level 2.

An analysis of health-related quality of life in children and adolescents after parotidectomy based on patient-reported outcomes

PURPOSE

To assess health-related quality of life (HRQoL) and its influencing factors in these pediatric patients undergoing parotidectomy.

METHODS

This was a cross-sectional study that included 37 children and adolescents (≤ 19 years) with parotid gland tumors who were treated in Sichuan Cancer Hospital between January 2006 and November 2021. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30). The Wilcoxon rank sum test was used to analyze the factors influencing patients' HRQoL.

RESULTS

37 children and adolescents were included in the study, including 22 cases of benign tumors and 15 cases of malignant tumors. All patients underwent surgery, and some patients with malignant tumors received radiotherapy or chemotherapy. Malignancy, permanent facial palsy, and Frey syndrome were associated with worse HRQoL in children and adolescents with parotid gland tumors. Radiotherapy and no cervical lymph node dissection were associated with worse HRQoL in pediatric patients with malignancy. The surgical approach of parotid is not a factor influencing HRQoL.

CONCLUSION

Factors associated with HRQoL in children and adolescents with parotid gland tumors include pathological types, permanent facial palsy, and Frey syndrome. In addition, factors affecting patients with malignancy include lateral lymph node dissection and radiotherapy.

Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare different tonsillectomy techniques in terms of postoperative bleeding incidence and postoperative pain.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were postoperative bleeding incidence and mean postoperative pain score.

RESULTS

A total of 6464 patients were included for five different interventions (cold dissection tonsillectomy; extracapsular coblation tonsillectomy; intracapsular coblation tonsillectomy [ICT]; bipolar diathermy tonsillectomy [BDT]; monopolar diathermy tonsillectomy). ICT showed the lowest absolute risk (4.44%) of postoperative bleeding incidence (73.31% chance of ranking first) and the lowest mean postoperative pain score (1.74 ± 0.68) with a 94.0% chance of ranking first, whereas BDT showed both the highest absolute risk of bleeding incidence (10.75%) and the highest mean postoperative pain score (5.67 ± 1.43).

CONCLUSIONS

ICT seems to offer better postoperative outcomes, in terms of reduced risk of bleeding and reduced pain. Further prospective studies are advised to confirm these findings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1696-1704, 2024.

Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force

The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey's syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.

Frey syndrome after conservative parotidectomy: Importance of closing the remnant parotid parenchyma

BACKGROUND

Frey syndrome (FS) is a typical late complication following parotidectomy. Parotid surgery without proper coverage or reconstruction of exposed parotid parenchyma may contribute to the development of FS. Therefore, this study compared the closure versus the non-closure of exposed parotid parenchyma in the occurrence of FS.

METHODS

This study included 195 patients with parotid lesions who underwent partial or superficial parotidectomy plus closure or non-closure of exposed parotid parenchyma, both with the application of fibrin glue. Two surgical methods of closure and non-closure were allocated to patients without randomization and blinding processes. The primary outcome was FS, and the second outcome was other complication rates.

RESULTS

The closure and non-closure of exposed parotid parenchyma were performed in 102 and 93 patients, respectively. Early postoperative complications occurred with temporary events: transient facial weakness, 32 (16.4%); hematoma, 13 (6.7%); and wound infection, 2 (1.0%), without statistical difference between the two groups (P > 0.1). However, sialocele occurred in the non-closure group (n = 19) more than in the closure group (n = 7) (P = 0.005). In the first postoperative year, decreased sensation and local pain were found in 16 patients (8.2%) and 9 patients (4.6%), respectively, with no statistical difference between the two groups (P > 0.1). FS was found more in the non-closure group (n = 19, 20.4%) than in the closure group (n = 4, 3.9%) (P < 0.001).

CONCLUSION

The closure of exposed parotid parenchyma and covering fascia is preferred over the non-closure to prevent FS.

Complications of pectoralis major myo-cutaneous flap, anterolateral thigh flap and radial forearm free flap after total laryngectomy with partial pharyngectomy: A systematic review and network meta-analysis

BACKGROUND

No consensus exists regarding the most effective reconstruction after total laryngectomy with partial pharyngectomy (TLwPP). This study aims to compare different reconstructive techniques (pectoralis major myo-cutaneous flap, PMMCF; anterolateral thigh flap, ALTF; radial forearm free flap, RFFF) after TLwPP in terms of pharyngocutaneous fistula (PCF), stenosis and feeding tube dependence (FTD) incidence.

METHODS

The Scopus, PubMed/MEDLINE, Cochrane Library, and Google Scholar databases were searched. A single-arm meta-analysis was performed for PCF incidence, stenosis incidence, and FTD incidence on the entire cohort. An arm-based network analysis was conducted to compare three different surgical interventions (PMMCF, ALTF, RFFF).

RESULTS

A total of 13 studies and 232 patients were included in the network meta-analysis. The lowest PCF absolute risk was measured for the RFFF (11.7%, 95% CI: 2.8%-33.4%), compared to the ALTF (13.4%, 95% CI: 4.5%-32.1%) and the PMMC (49.0%, 95% CI: 19.2%-79.3%). The RFFF showed a stenosis absolute risk of 0.0% (95% CI: 0.0%-1.1%), while a higher stenosis incidence was measured for the ALTF (5.7%, 95% CI: 0.8%-25.2%) and the PMMCF (11.6%, 95% CI: 0.8%-55.1%). The RFFF showed the lowest absolute risk of FTD incidence (6.8%, 95% CI: 0.5%-28.1%) compared to the other reconstructive techniques (PMMCF: 12.4%, 95% CI: 2.4%-42.1%; ALTF: 17.5%, 95% CI: 6.4%-38.9%).

CONCLUSIONS

The RFFF seems the best choice for reconstruction of partial pharyngeal defects after TLwPP due to the lower incidence of PCF, stenosis and FTD compared to the ALTF and the PMMCF.

Surgical prevention of pharyngocutaneous fistula in salvage total laryngectomy: a systematic review and network meta-analysis

PURPOSE

To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL).

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines.

RESULTS

A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62-66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20-0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first).

CONCLUSIONS

A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL.

Comparison of various surgical incisions in parotidectomy: A systematic review and network meta-analysis

Background

This network meta-analysis aimed to comprehensively compare the operative and postoperative outcomes of different parotidectomy incisions.

Methods

Embase, PubMed, Web of Science, and Cochrane Central Register of Controlled Trials were searched up to April 2022. A complete Bayesian network meta-analysis was performed using the Markov Monte Carlo method in OpenBUGS.

Results

Seventeen studies with 1609 patients were included. Thirteen were retrospective cohort studies, three were prospective cohort studies, and one was a randomized controlled study. The quality of evidence was rated as very low in most comparisons. The incision satisfaction score of the modified facelift incision (MFI), retroauricular hairline incision (RAHI), V-shaped incision (VI) were higher than that of the modified Blair incision (MBI) (MBI vs. MFI: mean difference [MD] -1.39; 95% credible interval [CrI] -2.23, -0.57) (MBI vs. RAHI: MD -2.25; 95% CrI -3.40, -1.12) (MBI vs. VI: MD -2.58; 95% CrI -3.71, -1.46); the tumor size treated by VI was smaller than that by MBI (MD 5.15; 95% CrI 0.76, 9.38) and MFI (MD 5.16; 95% CrI 0.34, 9.86); and the risk of transient facial palsy in the MFI was lower than that in the MBI (OR 2.13; 95% CrI 1.28, 3.64). There were no differences in operation time, drainage volume, wound infection, hematoma, salivary complications, Frey syndrome, or permanent facial palsy between incision types.

Conclusion

The traditional MBI is frequently used for large tumor volumes, but the incision satisfaction score is low and postoperative complication control is poor. However, emerging incisions performed well in terms of incision satisfaction scores and control of complications. More randomized controlled trials are needed to compare the different parotidectomy incisions. Patients should be fully informed about the characteristics of each incision to make the most informed decision, along with the physician’s advice.

Systematic Review Registration

PROSPERO, identifier CRD42022331756

Observation of Palatal Wound Healing Process Following Various Degrees of Mucoperiosteal and Bone Trauma in a Young Rat Model

Simple Summary

The exact correlation of palatal trauma to maxillary inhibition has not been demonstrated. This paper determines the influence of different degrees of palatal trauma on maxillofacial growth and assesses whether usage of ADM can help rescue the inhibited growth during palatal wound healing. This research would help the surgeons comprehensively understand the impact of palatal trauma on maxillary growth and the therapeutic effect of the ADM.

Abstract

The accidental injury or surgery on soft and hard palatal tissue has an adverse impact on normal maxillary morphology. To design a single-factor experiment that excludes other interfering factors on maxillary growth, a young rat model was established to simulate the various degrees of palatal trauma. Eight maxillary parameters were measured to evaluate the impact of palatal trauma on maxillary growth. Furthermore, the acellular dermal matrix (ADM) was applied to cure the palatal trauma and alleviate the adverse impact of bone denudation on the maxillary growth. Micro-CT scanning and histology analyses were used. One-way ANOVA with least significant difference (LSD) post-test was used to evaluate the statistical significance. The palatal trauma mainly disturbed the transverse development of the maxilla. ADM promotes mucosa healing, but there is still an inhibitory effect on maxillofacial growth.

Circumferential pharyngeal reconstruction after total laryngopharyngectomy: A systematic review and network meta-analysis

OBJECTIVE

To compare the functional outcomes of different reconstructive techniques for circumferential pharyngeal reconstruction.

METHODS

A comprehensive electronic search was performed on PubMed/MEDLINE, Cochrane Library, and Google Scholar databases. Retrospective and prospective studies were included. Two independent reviewers extracted thirty-four studies after applying the eligibility criteria. An arm-based network analysis was conducted using a Bayesian hierarchical model. The main outcomes were pharyngo-cutaneous fistula (PCF) incidence, stenosis incidence and feeding tube dependence (FTD) incidence. Network estimates from outcome variables were presented as absolute risks, odds ratio [OR] with 95% credible intervals (CIs), and ranking probability.

RESULTS

A total of 1357 patients were included for 5 different interventions (tubed pectoralis muscle myocutaneous flap, t-PMMCF; tubed anterolateral tight flap, t-ALTF; tubed radial forearm free flap, t-RFFF; free jejunal flap, FJF; U-shaped pectoralis muscle myocutaneous flap, u-PMMCF). FJF showed a 92.8% chance of ranking first in terms of pharyngo-cutaneous fistula prevention (absolute risk: 10%), while the highest PCF incidence (42%) was measured for t-PMMCF. u-PMMCF showed the lowest absolute risk (11%) of stenosis incidence (62.2% chance of ranking first). t-PMMCF (5%), FJF (8%), and u-PMMCF (8%) showed similar results in terms of feeding tube dependence, with a 53.2%, 23.1% and 18.9% chance of ranking first, respectively.

CONCLUSIONS

FJF seems to be the best reconstructive choice after total laryngo-pharyngectomy in terms of PCF, stenosis and FTD incidence. If this reconstructive method is not feasible, a u-PMMCF should be favored over tubed free and pedicled flaps. Further comparative studies are needed to confirm these results.

Comparing postoperative outcomes using electrocautery versus cold-knife de-epithelialization of dermal fat graft in parotidectomy reconstruction

PURPOSE

The present study was developed to evaluate the effectiveness of a simple rapid technique for de-epithelializing cutaneous flaps and grafts in parotidectomy reconstruction.

MATERIALS AND METHODS

109 patients who underwent a parotidectomy with abdominal free dermal fat graft (FDFG) reconstruction between 2018 and 2021 were evaluated based on demographic factors, past medical/surgical history, type of parotidectomy performed, operative factors, and post-operative complications. These data were then stratified based on de-epithelialization technique as well as tumor malignancy status to determine any differences in complication rates or perioperative factors between electrocautery (EC) and cold knife (CK) techniques within both benign and malignant subgroups.

RESULTS

77 of the 109 participants underwent FDFG de-epithelialization using monopolar electrocautery (EC) and the remaining 32 participants underwent de-epithelialization using traditional cold knife (CK) technique. There was no statistical difference among the two groups in overall complication rate. The EC group had a significantly shorter operation time ("EC vs. CK": 144.2 min vs. 174.7 min; p = 0.031). Additionally, histopathologic samples showed that both techniques left the underlying dermis intact and without damage.

CONCLUSIONS

This study demonstrated that there is no difference in complication rate or histology of FDFGs de-epithelialized using EC compared to CK. It was also shown that when controlling for confounders by looking solely at the benign subgroup of patients, EC de-epithelialization was a faster technique than CK. These findings suggest that EC is just as effective as CK, and may actually be a more efficient surgical technique to accomplish de-epithelialization of FDFG.

[Complications in the surgery of the parotid salivary glands. Causes, mechanisms of development, methods of prevention]

Operations for neoplasms of the parotid salivary gland require from the surgeon a deep knowledge of the anatomical and topographic features of this area and technical skill, which puts it in a number of «jewelry» operations that require patience and concentration. The review is devoted to the topic of specific postoperative complications after parotidectomy or subtotal resection of the gland. These include relapses of tumors, paralysis or paresis of facial muscles, Frey syndrome, salivary fistulas or sialocele, violation of skin sensitivity, soft tissue deformity. The review presents the frequency and causes of complications, mechanisms of their development, methods of prevention and elimination.

Infrahyoid myofascial flap transfer for the prevention of concave deformity and gustatory sweating after parotidectomy

OBJECTIVE

Concave deformities and gustatory sweating are the most common complications that cause substantial patient dissatisfaction after parotidectomy. Various surgical methods to prevent these complications have been described. However, effective techniques have not been established, especially in patients with medium- to large-sized parotidectomy defects. We evaluated the utility of infrahyoid myofascial flap reconstruction of parotidectomy defects for the prevention of these complications.

METHODS

We conducted a retrospective case series study in patients with a benign or malignant parotid tumor measuring over 4 cm who underwent immediate pedicle infrahyoid myofascial flap reconstruction after total or subtotal parotidectomy or total resection of either the superficial or deep parotid gland at our hospital. Subjective analyses of facial symmetry, postoperative concave deformities of the anterior neck, gustatory sweating, voice disorders, odynophagia, neck scarring in the parotid and anterior neck areas, sensory disorders, pain, and neck stiffness were performed using patient interview data. Objective evaluations of facial symmetry were made by the first or second author. Both analyses were performed after a follow-up of more than six months. Additionally, patient demographic data, clinicopathological factors, parotidectomy and skin incision types, flap survival, and postoperative complications were evaluated.

RESULTS

We included eight patients (male, n=5; mean age, 69.3 years [range, 37-93 years]). Procedures included total or subtotal parotidectomy (n=4), superficial lobe parotidectomy (n=2), and deep lobe parotidectomy with partial superficial lobe parotidectomy (n=2). Infrahyoid myofascial flaps reached the cranial tip of the parotid defect without tension, and their volume sufficiently filled the parotidectomy defect in all patients. There were no local signs of insufficient blood flow within the transferred flaps. OBJECTIVE AND SUBJECTIVE: assessments were made after a mean duration of 1.2 years (range, 0.6-1.8). Postoperatively, no patient subjectively reported facial asymmetry. Objectively, facial symmetry was "good" in four patients and "fair" in four patients. No distinctly visible concave deformity in the parotid or anterior neck area occurred in any patient. Gustatory sweating occurred in one patient; this individual had the largest parotidectomy defect. Only one patient experienced donor site morbidity (mild anterior neck stiffness) related to infrahyoid myofascial flap elevation.

CONCLUSION

Although complete prevention of gustatory sweating was unsuccessful, infrahyoid myofascial flap reconstruction of medium- to large-sized parotidectomy defects led to postoperative facial symmetry with minimal donor site morbidity.

Frey's syndrome: A review of the physiology and possible role of neurotrophic factors

OBJECTIVES

Frey's syndrome (FS) describes the phenomenon of gustatory sweating and is a cause of significant social embarrassment for sufferers. It has been attributed to aberrant growth of parasympathetic salivatory fibers in the auriculotemporal nerve toward overlying sweat glands. However, the exact mechanism behind this growth is unknown. This review aims to expand and elucidate the theory of aberrant regeneration in FS.

METHODS

A review of the recent literature on nerve regeneration was conducted in order develop further insights into the etiology of both adult onset and pediatric FS.

RESULTS

Neurturin, a neurotrophic factor released by both salivary and sweat glands, was identified as a possible key player in the etiology of FS.

CONCLUSION

Further research into the role of neurturin could help to elucidate the pathogenic mechanisms underlying the condition and might reveal neurturin to be a potential target for pharmacological intervention.

LEVEL OF EVIDENCE

NA (Basic Science Review).