Long-term effects of parotidectomy

Quality of Life Outcomes for Parotid Malignancies

BACKGROUND

This study describes patient-reported outcome measures (PROMs) and associated factors in patients who underwent surgery for malignant parotid tumors (MPT).

METHODS

This is a retrospective study of all surgically treated MPT patients in a multidisciplinary head and neck cancer (HNC) survivorship clinic (2017-2023). PROMs included University of Washington Quality of Life Questionnaire (UW-QOL), Eating Assessment Tool (EAT-10), Patient Health Questionnaire (PHQ-8), Generalized Anxiety Disorder (GAD-7), Neck Disability Index (NDI), and Insomnia Severity Index. Multivariable regression analysis was used to investigate clinical predictors associated with PROMs.

RESULTS

In 62 MPT patients, the prevalence of clinically relevant dysphagia symptoms (EAT-10), elevated symptoms of depression (PHQ-8), moderate/severe symptoms of anxiety (GAD-7), moderate/severe neck pain with activities of daily living (NDI), and moderate/severe symptoms of insomnia at last follow-up was 32.3%, 15.5%, 7.1%, 17.7%, and 7.2%, respectively. Nonparametric one-sided test revealed that patients treated with adjuvant CRT had significantly worse physical QOL, social-emotional QOL, and swallowing scores than patients treated with surgery alone (p = 0.01, p = 0.02, p = 0.03, respectively); that patients treated with surgery and adjuvant RT had significantly worse physical QOL and social-emotional QOL than patients treated with surgery alone (p < 0.01, p = 0.01, respectively) and that patients treated with surgery and adjuvant CRT had significantly worse swallowing and neck pain than patients treated with surgery and adjuvant RT (p = 0.03, p = 0.05, respectively).

CONCLUSIONS

In patients with surgically treated MPT, adjuvant CRT and RT were associated with worse PROMs.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Postauricular Incision Versus Modified Blair Incision in Parotidectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

The mainstay of first-line treatment of parotid tumors is adequate surgical removal. The present study was conducted to compare the differences between parotidectomy with postauricular incision (PI) and modified Blair incision (MBI).

DATA SOURCES

A systematic search of PubMed, Embase and the Cochrane Library was performed.

METHODS

The data of interest and study characteristics were extracted from the included studies. Statistical analysis was performed with Comprehensive Meta-Analysis software (version 3; BioStat, Englewood, NJ). Dichotomous data and continuous data were analyzed by calculating the risk difference and the mean difference with the 95% confidence interval respectively.

RESULTS

Four retrospective studies were included in the present meta-analysis. The pooled results revealed that the cosmetic satisfaction score was higher in the PI group (MD = 2.67; 95% CI, 2.12 to 3.23) and that intraoperative blood loss was lower in the PI group (MD =  -55.35; 95% CI, -100.33 to -10.36). The operative duration (MD  =  -5.15; 95% CI, -24.06 to 13.75), tumor size (MD  =  -.07; 95% CI, -.27 to .13) and incidences of common postoperative complications were comparable between the two groups.

CONCLUSIONS

According to these findings, the use of PI in parotidectomies may be one of the options for improving cosmetic outcomes. This technique may be considered if oncological safety can be secured.

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

Long-term outcomes and quality of life following parotidectomy for benign disease

Objective

Parotidectomy worsens quality of life (QoL) in the short-term, but the long-term impact is unknown. In this study, we analysed the long-term effects of parotidectomy on QoL.

Methods

In this prospective long-term follow-up study, participants were divided into three groups: short-term (ST) follow-up of six weeks, long-term (LT) follow-up of 13 years and short- and long-term (SLT) follow-up. QoL was assessed using the Parotidectomy Outcome Inventory (POI-8). Parotidectomies were classified based on whether the great auricular nerve (GAN) had been preserved or sacrificed.

Results

In total, 164 observations were analysed, 74 in the LT group, 57 in the ST group and 33 in the SLT group. Hypoaesthesia was a major problem and facial palsy was a minor problem. Pain (p < 0.01) and hypoaesthesia (p < 0.001) were significantly lower after 13 years compared with after six weeks, and QoL was higher after 13 years compared with after six weeks (p = 0.04). The disease-specific impairment rate decreased from 70% at short-term follow-up to 30% at long-term follow-up. Removal of the GAN was associated with hypoaesthesia in the ST group (p = 0.028).

Conclusions

Hypoaesthesia has a long-term impact on the QoL, and this should be emphasised during preoperative discussions.

Systematic review and meta-analysis of modified facelift incision versus modified Blair incision in parotidectomy

Surgical removal is the treatment of choice for many neoplasms of the parotid gland. This meta-analysis aimed to evaluate the differences between parotidectomy using a modified facelift incision (MFI) and parotidectomy using a modified Blair incision (MBI). A systematic search of the available literature in PubMed, Embase and the Cochrane Library was performed. Studies of adult patients who underwent open parotidectomy with presumed benign parotid neoplasms based on preoperative examinations were reviewed. The surgical outcomes of the MFI and MBI groups were collected. Intraoperative and postoperative parameters, including operative time, tumor size, cosmetic satisfaction, and incidences of facial palsy, Frey's syndrome and salivary complications, were compared. Dichotomous data and continuous data were analyzed by calculating the risk difference (RD) and the mean difference (MD) with the 95% confidence interval (CI), respectively. Seven studies were included in the final analysis. The pooled analysis demonstrated that the cosmetic satisfaction score was significantly higher in the MFI group (MD = 1.66; 95% CI 0.87-2.46). The operative duration in the MFI group was significantly longer than that in the MBI group (MD = 0.07; 95% CI 0.00-0.14). The MFI group exhibited a smaller tumor size (MD = - 2.27; 95% CI - 4.25 to - 0.30) and a lower incidence of Frey's syndrome (RD = - 0.18; 95% CI - 0.27 to - 0.10). The incidence of postoperative temporary facial palsy (RD = - 0.05; 95% CI - 0.12 to 0.03), permanent facial palsy (RD = - 0.01; 95% CI - 0.06 to 0.03) and salivary complications (RD = - 0.00; 95% CI - 0.05 to 0.05) was comparable between the two groups. Based on these results, MFI may be a feasible technique for improving the cosmetic results of patients who need parotidectomy when oncological safety can be ensured.

The effects of residual parotid volume on symptom-specific quality of life and complications in patients undergoing parotid surgery

PURPOSE

To measure postoperative residual parotid volumes in parotidectomy patients and to measure the effect of residual parotid volumes on the symptom-specific quality of life (SSQOL) and complications.

METHODS

Between January 2010 and December 2016, 148 parotid gland surgeries were performed, and 74 patients were included in the study. Bilateral parotid gland volumes were measured by Magnetic Resonance Imaging (MRI). Parotidectomy Outcome Inventory-8 and aesthetic scale questionnaire were applied to the patients. The volumetric averages obtained were compared with the questions in the SSQOL scale, the aesthetic scale data, and complications.

RESULTS

In the volumetric examination performed with MRI, the mean residual volumes of the operated parotid glands were 9.5 cm³, while the non-operated side was 28.8 cm³. The width of the surgery and the residual parotid tissue volume was inversely correlated. There was a statistically significant difference between the residual parotid gland volume and the pain related to the surgical area, depression in the surgical site, Frey's syndrome, incision scar, and numbness. As the residual parotid gland volumes decreased, the patients' cosmetic problems related to the surgical field increased significantly, and their SSQOL decreased.

CONCLUSION

Postoperative residual parotid tissue volume could be an objective parameter to measure patients' SSQOL and complications. After parotidectomy, the maximum amount of disease-free tissue of the parotid gland should be left in place to increase patients' quality of life and minimize complications.

Perioperative Complications after Parotidectomy Using a Standardized Grading Scale Classification System

Perioperative complications after parotidectomy are poorly studied and have a potential impact on hospitalization stay. The Clavien–Dindo classification of postoperative complications used in visceral surgery allows a recording of all complications, including a grading scale related to the severity of complication. The cohort analyzed for perioperative complications is composed of 436 parotidectomies classified into three types, four groups, and three classes, depending on extent of parotid resection, inclusion of additional procedures, and pathology, respectively. Using the Clavien–Dindo classification, complications were reported in 77% of the interventions. In 438 complications, 430 (98.2%) were classified as minor (332 grade I and 98 grade II), and 8 (1.8%) were classified as major (grade III). Independent variables affecting the risk of perioperative complications were duration of surgery (odds ratio = 1.007, p-value = 0.029) and extent of parotidectomy (odds ratio = 4.043, p-value = 0.007). Total/subtotal parotidectomy was associated with an increased risk of grade II-III complications (odds ratio = 2.866 (95% CI: 1.307–6.283), p-value = 0.009). Median hospital stay increased moderately in patients with complications. Use of Clavien–Dindo classification shows that parotidectomy is followed by a higher rate of perioperative complications than usually reported. Almost all complications are minor and have limited consequence on hospital stay.

Factors associated with facial weakness following surgery for benign parotid disease: a retrospective multicenter study

BACKGROUND

Facial nerve weakness is the most common and most concerning complication after parotidectomy. Risk factors for this complication following surgery for benign diseases remain controversial.

OBJECTIVE

Review the frequency and prognosis of facial nerve weakness after parotidectomy and analyze potential risk factors.

DESIGN

Retrospective review of medical records.

SETTINGS

Two tertiary care centers.

PATIENTS AND METHODS

We included all parotidectomies performed for benign diseases from January 2006 to December 2018. Details about the development and recovery of postoperative facial weakness were recorded. Patient, disease and surgery-related variables were analyzed using bivariate and multivariate analyses to identify risk factors.

MAIN OUTCOME MEASURES

Frequency, recovery rates and risk factors for facial nerve weakness SAMPLE SIZE: 191 parotidectomies, 183 patients, 61 patients with facial weakness.

RESULTS

The frequency of postoperative facial weakness was 31.9% (61/191 parotidectomies). Among patients with temporary weakness, 90% regained normal facial movement within 6 months. Steroid therapy was not associated with a faster recovery. Postoperative weakness was not associated with age, diabetes, smoking, disease location, use of an intraoperative facial nerve monitor or direction of facial nerve dissection. Risk factors for temporary weakness were total parotidectomy and surgical specimens larger than 60 cubic centimeters. Revision surgery was the only identified risk factor for permanent weakness.

CONCLUSION

Larger parotid resections increase the risk of temporary facial nerve weakness while permanent weakness is mainly influenced by previous surgeries.

LIMITATIONS

Retrospective nature, underpowered sample size, selection bias associated with tertiary care cases.

CONFLICT OF INTEREST

None.

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.

Real impact of surgical robotic system for precision surgery of parotidectomy: retroauricular parotidectomy using da Vinci surgical system

Background

We performed robotic parotidectomy with or without robotic neck dissection via a retroauricular approach in patients with parotid benign and malignant tumors and analyzed treatment outcomes of the patients to evaluate the safety and feasibility of robotic parotidectomy.

Methods

Between January 2017 and July 2018, 53 patients received robotic parotidectomy with/without robotic neck dissection through a remote access retroauricular incision without a preauricular incision.

Results

All operations were successfully performed in all patients without significant perioperative complications or tumor spillage. Tumors were located in the superficial lobe of the parotid gland in 40 patients, and the remaining 13 tumors were located in the deep lobe of the parotid gland. Postoperative pathologic examination revealed benign tumor in 32 patients and malignant tumors in 18 patients. The mean operation time was 226 minutes in patients who underwent only parotidectomy and 375 minutes in patients who underwent parotidectomy with robotic neck dissection. The average amount of bleeding was 23 mL, and the amount of drainage after operation averaged 171 mL. The average length of hospital stay was 6 days. Postoperative complications were limited to transient facial paralysis in three patients, all of which resolved within 1 month. All patients were satisfied with their cosmetic results at 6 months after operation.

Conclusions

Robotic parotidectomy with/without robotic neck dissection through a retroauricular approach was a feasible and safe technique in patients with parotid benign and malignant tumor. Specifically, we found it to be helpful in young patients with malignant parotid tumors who should receive cervical lymphadenectomy and parotidectomy, because it does not leave a visible scar on the face or neck. In the future, long-term follow-up will be necessary to validate its oncologic safety and functional outcomes.

Parotidectomy in patients with head and neck cutaneous melanoma with cervical lymph node involvement

BACKGROUND

Parotidectomy in melanoma of the coronal scalp and face with clinically involved cervical lymph node metastasis is based on predicted cervical lymphatic drainage described by O'Brien.

METHODS

In total, 40 parotidectomies with en bloc therapeutic neck dissection were retrospectively analyzed.

RESULTS

Lymphatic spread of melanoma to the parotid lymph nodes was observed in 10 of 40 specimens (25%). Eight of the 10 parotid-positive patients developed a recurrence vs 17 of the 30 parotid-negative patients (P = 0.28). There were no differences in overall survival, melanoma-specific survival, and disease-free survival between the parotid-positive and parotid-negative patients.

CONCLUSION

Although in this series no survival differences were found, parotidectomy still merits a sustained role in therapeutic neck dissection procedures to improve regional control and to prevent facial nerve damage after surgery for a second relapse from occult metastases in the parotid.

Segmental superficial parotidectomy in the surgical treatment of benign parotid tumours

Objective:

To evaluate the efficacy and safety of segmental superficial parotidectomy in the surgical treatment of benign parotid tumours.

Methods:

Patients who underwent parotidectomy for benign primary parotid tumours limited to the superficial lobe were retrospectively reviewed. Tumour location, size, surgical procedure, follow-up period, complications and recurrence rates were noted.

Results:

The study included a total of 39 patients: 22 underwent segmental superficial parotidectomy (group 1) and 17 underwent superficial parotidectomy (group 2). The mean follow-up period was 41.79 months (range, 13–85 months). There were no recurrences in either group during the follow-up period. No significant differences were found between the two groups in terms of tumour size, complications or recurrence rates.

Conclusion:

Segmental superficial parotidectomy is a safe and effective option in the surgical treatment of benign parotid tumours.

Reoperation following the use of non-standardized procedures for malignant parotid tumors

Non-standardized or conservative procedures are employed when parotid tumors involving the facial nerve or parotid carcinoma are misdiagnosed as benign parotid tumors prior to or during surgery. Remedial measures are usually required when the pathological diagnosis of a malignant parotid tumor is confirmed following surgery. The aim of the present study was to systematically evaluate reoperation subsequent to treatment with non-standardized procedures for malignant parotid tumors, and to explore the preoperative diagnoses, the primary procedure selection and the necessity of reoperation following non-standardized procedures in malignant parotid tumors. A total of 30 patients who met the inclusion criteria, were diagnosed with a malignant parotid tumor and underwent reoperation following the use of a non-standardized procedure were included in the present study. Surgical conditions and clinical data were analyzed. Among the patients with a malignant parotid tumor who underwent reoperation subsequent to a non-standardized procedure, the incidence of residual tumor, as confirmed by pathological examination, was 63.3% (19/30). The intact facial nerve preservation rate was 83.3% (25/30), the facial nerve branch resection rate was 6.7% (2/30), the facial partial nerve resection rate was 6.7% (2/30) and the facial nerve resection rate was 3.3% (1/30). In total, 3 patients underwent facial nerve reconstruction, 3 patients underwent a local flap repair of skin defects in the parotid region and 3 patients underwent pectoralis major muscle flap repair. The current findings indicate that the qualitative diagnosis of malignant parotid tumors prior to surgery is difficult, there is a high incidence of residual tumor following non-standardized procedures, and that reoperation in a timely manner is required in such cases.