Great auricular nerve preservation in parotid surgery: rationale and long-term results insights

Retromandibular Vein, Digastric Muscle, and Greater Auricular Nerve in Superficial Parotidectomies for Patients with Pleomorphic Adenoma-A Surgical Experience

Retromandibular vein (RMV) and posterior belly of digastric muscle are among the landmarks used to identify facial nerve in parotid surgery. This observational cross-sectional study was done in the Department of ENT &HNS at a tertiary care teaching hospital for a period of 8 years with the aim to aware young otorhinolaryngologist about the relationship of posterior belly of digastric muscle & retromandibular vein with facial nerve and share our experience about preservation of posterior branch of greater auricular nerve. A total of 34 cases of superficial parotidectomies done for pleomorphic adenoma were included in this study. Relationship of facial nerve with retromandibular vein and posterior belly of digastric muscle was noted. Greater auricular nerve was identified, and every attempt was made to preserve its posterior branch. Retromandibular vein was medial to the trunks of facial nerve in 33 (97%) patients. It was lateral to lower division and medial to upper division in one case. Greater auricular nerve was seen to bifurcate into two branches (Anterior and posterior) in 21 (62%) cases while in one case(3%) three branches were seen emerging from main trunk and in another case(3%) first two branches were seen emerging and then anterior branch was further dividing into two. Preservation of posterior branch of greater auricular nerve was possible in 23 (68%) of patients. Posterior belly of digastric muscle was seen as a reliable and constant landmark. Facial nerve was seen superior to upper border of posterior belly of digastric muscle in all cases (100%). No anatomical variation of posterior belly was seen. Retromandibular vein is invariably seen medial to the trunks of facial nerve. Facial nerve is always seen superior to upper border of posterior belly of digastric muscle in almost all cases. Preservation of posterior branch of greater auricular nerve is possible in majority of the cases.

Is This Novel Incision for Benign Parotid Tumors the Answer for Improved Esthetics and Access?

Background

Incision scars and postoperative cosmesis are critical in the management of benign parotid tumors. Traditional incisions have a typical visible scar in the retromandibular area or require wide skin flaps.

Purpose

In this study, we introduced a new surgical approach called the tri-split flap approach and evaluated its technical feasibility and surgical outcomes.

Materials and Methods

Eleven patients with clinically benign parotid gland tumors underwent the tri-split flap approach and were followed for six to ten months postoperatively. Facial weakness, salivary fistula formation, first bite syndrome, earlobe numbness, and the subjective cosmetic results were evaluated.

Results

All tumors were completely excised, and the patients were highly satisfied with the esthetic outcome of the surgery. No patients developed wound dehiscence, facial nerve injury, or first bite syndrome during the follow-up period. One patient developed a minor salivary fistula that resolved after three weeks.

Conclusion

The tri-split flap approach not only provides adequate exposure of the surgical site to achieve complete resection of benign parotid gland neoplasms but also results in a very short and highly concealed post-operative scar. This technique is a potential surgical approach in parotidectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-021-01605-1.

Great auricular nerve conservation and parotidectomy for tumor

OBJECTIVE

To describe the key technical points for preserving the great auricular nerve during parotidectomy for tumor, and to discuss the literature regarding the benefits, limitations and indications for nerve-sparing surgery. Data suggested that great auricular nerve preservation should be discussed in the preoperative consultation, attempted intraoperatively and mentioned in the operative report once parotidectomy completed.

Impact of great auricular nerve sacrifice on sensory disturbance after parotidectomy

PURPOSE

To investigate the association between great auricular nerve (GAN) sacrifice during parotidectomy and postoperative sensory disturbance.

MATERIALS AND METHODS

Patients who underwent parotidectomy between November 2016 and May 2020 at a single academic institution were included in this retrospective chart review. Operative notes were reviewed to determine incidence of GAN sacrifice. Prevalence of patient-reported sensory complaints in the GAN distribution and time to spontaneous resolution of symptoms were assessed.

RESULTS

Of 305 parotidectomy patients, 111 (36.4%) endorsed complaints of postoperative sensory disturbances in the GAN distribution typically characterized by numbness or shooting pains. GAN sacrifice was present in 9 (8.1%) of 111 patients who experienced sensory disturbances compared to 9 (4.6%) who reported no sensory disturbances (p > 0.05). Twenty-five patients (32.5%) experienced spontaneous resolution of symptoms at their most recent follow-up at a mean of 6.2 months after onset of symptoms. Of those that experienced a sensory disturbance, GAN preservation was not significantly associated with likelihood of spontaneous recovery (p > 0.05).

CONCLUSIONS

We report the largest series to date of post-operative sensory disturbance in parotidectomy patients as it relates to intraoperative GAN sacrifice. Although the relationship between GAN sacrifice and the incidence of postoperative sensory disturbance and its subsequent resolution were not significant, we continue to advocate for GAN preservation to reduce incidence of postoperative sensory disturbances.

[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.

A comprehensive review of the great auricular nerve graft

The great auricular nerve (GAN) is a superficial branch of the cervical plexus that innervates parts of the mandible, auricle, and earlobe. Over the past 30 years, the GAN has become the nerve graft donor of choice for many surgeons for reconstructing injured facial nerves. In this review, we discuss the anatomy and function of the GAN, while focusing on surgical landmarks and the characteristics that make it a suitable nerve graft donor. In addition, we present and summarize published case reports on use of the GAN for grafting. We hope that this review will provide surgeons with an up-to-date and concise reference.

Longitudinal perioperative pain, neuromusculoskeletal complications and quality-of-life assessment in partial parotidectomy

AIM

The aim of this study was to evaluate the pain, neuromusculoskeletal complications, and quality of life (QoL) in patients who had undergone partial parotidectomy (PP) for benign parotid tumors.

PATIENTS AND METHODS

All patients were evaluated before (T0) and at 1 week (T1) and 1 month (T2) after surgery. The patients were assessed for cervical range of motion (ROM), neck pain (NRS), neuropathic pain (DN4), neck disability (NDI), facial disability (FDI), and the presence of facial neuropathy, and QoL.

RESULTS

Twenty patients were included. A slight decrease was noted in cervical ROM, mild neck pain and disability were seen in T1. The DN4 score markedly increased at T1 (4.25) compared to T0 (0.1). Then it declined to 1.95 at T2. While there was no neuropathy in any of the patients at T0, it was present in 3 patients at T1. However, all improved at T2. QoL was negatively affected at T1 but showed improvement at T2. There was a significant correlation between NRS and NDI, FDI.

CONCLUSION

Neuromusculoskeletal problems and impaired QoL may develop in patients who have undergone PP. It would be beneficial to evaluate these patients using a multidisciplinary approach and inform them before surgery.

Minor Parotidectomy Complications: A Systematic Review

OBJECTIVES

To report descriptive statistics for minor parotidectomy complications.

METHODS

A systematic review was performed, selecting 235 studies for analysis. The incidence of complications was tabulated, and descriptive statistics calculated. Outlier studies, 1 standard deviation above the mean, were reexamined to determine potential causal factors for each complication. All studies were examined for statistically significant differences for any potential causal factor.

RESULTS

The pooled incidence of minor complications reported were hematoma 2.9% (95% confidence interval [CI]: 2.4-3.5), wound infection 2.3% (95% CI: 1.8-2.9), sialocele 4.5% (95% CI: 3.5-5.7), salivary fistula 3.1% (95% CI: 2.6-3.7), flap necrosis 1.7% (95% CI: 1.1-2.5), scar issues 3.6% (95% CI: 2.4-5.4), numbness 33.9% (95% CI: 25.6-43.4), and deformity 11.8 (95% CI: 6.9-19.5). Implants result in more wound complications, such as hematoma, sialocele, or salivary fistula. Sialocele and salivary fistula appear more frequently after less extensive parotid surgery, whereas hematoma, wound infections, flap necrosis, and aesthetic considerations are worse with more extensive resections.

CONCLUSIONS

Minor parotidectomy complications are more frequent than generally assumed and related to certain factors that should be investigated. Laryngoscope, 131:571-579, 2021.

Parotid tumours: clinical and oncologic outcomes after microscope-assisted parotidectomy with intraoperative nerve monitoring

Temporary and permanent facial nerve dysfunctions can be observed after parotidectomy for benign and malignant lesions. Intraoperative nerve monitoring is a recognised tool for the preservation of the nerve, while the efficacy of the operative microscope has been rarely stated. The authors report their experience on 198 consecutive parotidectomies performed on 196 patients with the aid of the operative microscope and intraoperative nerve monitoring. 145 parotidectomies were performed for benign lesions and 53 for malignancies. Thirteen patients treated for benign tumours experienced temporary (11 cases) or permanent facial palsy (2 cases, both of House-Brackmann grade II). Ten patients with malignant tumour presented with preoperative facial nerve weakness that did not improve after treatment. Five and 6 patients with malignant lesion without preoperative facial nerve deficit experienced postoperative temporary and permanent weakness respectively (the sacrifice of a branch of the nerve was decided intraoperatively in 2 cases). Long-term facial nerve weakness after parotidectomy for lesions not directly involving or originating from the facial nerve (n = 185) was 2.7%. Patients treated for benign tumours of the extra facial portion of the gland without inflammatory behaviour (n = 91) had 4.4% facial nerve temporary weakness rate and no permanent palsy. The combined use of the operative microscope and intraoperative nerve monitoring seems to guarantee facial nerve preservation during parotidectomy.

Complications after superficial parotidectomy for pleomorphic adenoma

Background

The significance of complications after superficial parotidectomy remains unclear, since prospective studies are lacking. The aim of this study was to evaluate facial nerve dysfunction and other postoperative complications after superficial parotidectomy for pleomorphic adenoma of the superficial lobe and to identify the associated risk factors.

Material and Methods

Prospective and descriptive clinical study on 79 patients undergoing formal superficial parotidectomy with the modified facelift incision, dissection of the facial nerve and reconstruction with the superficial musculoaponeurotic system flap. Function of the facial nerve using the House-Brackmann scale and the intra- and postoperative complications were recorded at 1 week and 1, 3, 6 and 12 months. A descriptive, inferential and binary logistic regression analysis were performed for the variables facial nerve dysfunction, tumor size and location, clinical presentation and duration of surgery.

Results

77.2% of the patients presented facial paresis at 1 week, with the marginal-mandibular branch being the most commonly affected (64.5%). 94.9% recovered the facial function at 6 months and 100% at 12 months. A statistically significant relationship was found between the appearance of facial paresis and tumor location in the superior lateral area of the superficial lobe, size >2 cm and prolonged operative time. None of the remaining variables showed significant differences at any study timepoint. At 12 months, 57% of patients had recovered tactile sensitivity in the earlobe. The clinical occurrence of Frey’s syndrome was 11.4%.

Conclusions

Despite the high incidence of postoperative facial paresis at 1 week, its magnitude was low and the recovery time was short. Tumor location in the parotid superficial lobe upper area, size and prolonged operative time are risk factors that can worsen facial paresis at different study timepoints. The knowledge of these complications is relevant for patient´s counseling and to achieve better long-term outcomes.

Key words:Superficial parotidectomy, pleomorphic adenoma, parotid gland, facial nerve paralysis, postoperative complications.

Sensation loss after superficial parotidectomy: A prospective controlled multicenter trial

BACKGROUND

The purpose of this study was to evaluate the occurrence of hypoesthesia after superficial parotidectomy depending on preservation of posterior branch of the great auricular nerve (GAN).

METHODS

This prospective, controlled, double blind, multicenter trial included 130 patients. The posterior branch was preserved in 93 patients (GAN group), and ligated in 33 patients (non-GAN group). In 4 patients, GAN status was unknown. Included patients underwent sensory testing (TouchTest) and subjective evaluation at 6, 12, and 24 months after surgery.

RESULTS

Better improvement of sensation was present in the GAN group. After 12 months, 59% of the patients in the GAN-group showed positive test results in the lobule, versus 24% of the non-GAN group (p = .013). Additionally, after 24 months, 71% of the patients in the GAN-group showed a positive test in the antitragus, versus 31% in the non-GAN group (p = .045). Hypoesthesia equally limited quality of life in both groups (all p > .05).

CONCLUSION

Preservation of the posterior branch of the GAN led to significantly better improvement of sensation in the lobule and antitragus, and should be recommended during parotidectomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 520-526, 2017.

Improved facial nerve identification during parotidectomy with fluorescently labeled peptide

OBJECTIVES/HYPOTHESIS

Additional intraoperative guidance could reduce the risk of iatrogenic injury during parotid gland cancer surgery. We evaluated the intraoperative use of fluorescently labeled nerve binding peptide NP41 to aid facial nerve identification and preservation during parotidectomy in an orthotopic model of murine parotid gland cancer. We also quantified the accuracy of intraoperative nerve detection for surface and buried nerves in the head and neck with NP41 versus white light (WL) alone.

STUDY DESIGN

Twenty-eight mice underwent parotid gland cancer surgeries with additional fluorescence (FL) guidance versus WL reflectance (WLR) alone. Eight mice were used for additional nerve-imaging experiments.

METHODS

Twenty-eight parotid tumor-bearing mice underwent parotidectomy. Eight mice underwent imaging of both sides of the face after skin removal. Postoperative assessment of facial nerve function measured by automated whisker tracking were compared between FL guidance (n = 13) versus WL alone (n=15). In eight mice, nerve to surrounding tissue contrast was measured under FL versus WLR for all nerve branches detectable in the field of view.

RESULTS

Postoperative facial nerve function after parotid gland cancer surgery tended to be better with additional FL guidance. Fluorescent labeling significantly improved nerve to surrounding tissue contrast for both large and smaller buried nerve branches compared to WLR visualization and improved detection sensitivity and specificity.

CONCLUSIONS

NP41 FL imaging significantly aids the intraoperative identification of nerve braches otherwise nearly invisible to the naked eye. Its application in a murine model of parotid gland cancer surgery tended to improve functional preservation of the facial nerve.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:2711-2717, 2016.