Partial parotidectomy under local anesthesia for benign parotid tumors - An experience of 50 cases

Local anaesthesia with conscious sedation in parotid gland tumour resection: a retrospective review

OBJECTIVES

This study explored the suitability of local anaesthesia with conscious sedation for parotid gland tumour surgery.

METHODS

Three hundred sixty-four medical records were reviewed to gather data on several key aspects for retrospective analysis. These included age, incision length, operation time, tumour size, NNIS score, ASA score, and pathology. Additionally, we documented postoperative complications.

RESULTS

A total of 111 patients underwent surgery under local anaesthesia with conscious sedation, while 253 patients underwent surgery under general anaesthesia. We found significant differences in surgical time, incision length, tumour location and tumour size between the two groups. There was no difference in postoperative complications or age.

CONCLUSIONS

Performing parotid gland tumour resection under local anaesthesia with conscious sedation is feasible. Compared with general anaesthesia, this approach does not increase the risk of complications or surgical trauma and can reduce the risk of anaesthesia-related complications. This is beneficial for expanding surgical treatment indications, allowing some patients who cannot tolerate general anaesthesia to also receive treatment.

Partial Parotidectomy under Local Anaesthesia without Regional Block Assisted by Electromyographic Facial Nerve Monitoring - A Case Report

The Rationale

This study describes a partial parotidectomy (PP) under local anaesthesia (LA) without regional block (LAwRB) assisted by electromyographic monitoring of the facial nerve, to consolidate the feasibility, efficacy and safety of these procedures without general anaesthesia (GA).

Patient Concerns

An 82-year-old with a lump in the left parotid gland suspected for non-Hodgkin lymphoma (NHL) needed a histological examination to start chemotherapy.

Diagnosis and Treatments

Because of multiple comorbidities, the authors performed a PP under LAwRB electromyographically guided by the NIM Vital (Medtronic)™.

Outcomes

The procedure was quick and did not require conversion to GA. The histopathological examination confirmed the NHL. No haematoma, sialocoele, earlobe numbness and transient or permanent facial palsy were observed.

Take-Away Lessons

The electrophysiologic monitoring of the facial nerve improves the efficacy, safety and feasibility of parotid surgery under LA, avoiding adverse effects of GA, need of regional block and reducing hospital stay.

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.

Patient safety and quality improvements in parotid surgery

Parotidectomy is the mainstay treatment for tumors of the parotid gland. In an effort to improve clinical outcomes, several modern surgical techniques and perioperative interventions have been evaluated and refined. This review discusses current and actively debated perioperative interventions aimed at improving patient safety and the quality of parotidectomy. Relevant high-impact literature pertaining to preoperative diagnostic modalities, intraoperative surgical techniques, and postoperative care will be described.

Observation Rather than Surgery for Benign Parotid Tumors: Why, When, and How

Surgery is the preferred treatment of benign parotid lesions, but it carries a risk of complications. Therefore, the approach toward the surgery of these lesions should seek to avoid complications. There are no guidelines or recommendations for when not to operate. Integration of comorbidities and other factors shift the scales from surgery toward observation in a small subset of patients presenting with parotid tumors. When observation is chosen, the patient should be followed frequently and cautiously, and the surgeon should be prepared to change strategy to surgical excision if in doubt.

Comparison of Parotidectomy With Observation for Treatment of Pleomorphic Adenoma in Adults

Importance

There is no consensus regarding optimal management of pleomorphic adenoma in adults.

Objectives

To compare parotidectomy with observation for the management of pleomorphic adenoma in patients 50 years or older by age.

Design and Setting

This decision analytical model was performed from November 21, 2019, to June 15, 2020, using a Markov model. Model variables and ranges were selected based on a literature review. A 1-way sensitivity analysis was performed to evaluate the age threshold at which each algorithm, either upfront elective parotidectomy or observation, would be favored. A Monte Carlo probabilistic sensitivity analysis using variable ranges was then performed 5 times with patients in the model assigned a starting age of 50, 60, 70, 80, and 90 years to assess how age at diagnosis would be associated with the model results.

Main Outcomes and Measures

Model outcomes were measured with quality-adjusted life-years (QALYs).

Results

In the study models, the age thresholds at which observation became more beneficial than parotidectomy were 88.5 years for patients with superficial lobe tumors (5.37 QALYs in favor of parotidectomy below this age, and 5.37 QALYs in favor of observation above this age) and 83.4 years for patients with deep lobe tumors (7.51 QALYs in favor of surgery below this age, and 7.51 QALYs in favor of observation above this age). There was no significant difference in outcomes between parotidectomy and observation among patients aged 70 to 80 years.

Conclusions and Relevance

This study suggests that the outcomes associated with parotidectomy and observation are similar at 70 years or older among patients with pleomorphic adenoma and that observation may be the favorable treatment in that age group.

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.

Retrograde parotidectomy under local anesthesia for benign, malignant, and inflammatory lesions

OBJECTIVE

To report the patient selection, surgical technique, and outcomes of parotidectomy using local anesthesia under monitored anesthesia care (MAC).

METHODS

A retrospective chart review was performed for patients undergoing parotidectomy under local anesthesia at an academic head and neck surgery center.

RESULTS

Six patients deemed high risk for general anesthesia (GA) due to medical comorbidities or with a strong preference to avoid GA underwent parotidectomy using local anesthesia and MAC. Parotidectomy was performed for several indications, including benign tumors, malignant tumors, and chronic sialadenitis. Mean age of patients was 78.0 ± 7.9 years, and all had an American Society of Anesthesia score ≥ 2 and Charlson comorbidity index ≥4. Mean operative time was 102.8 ± 38.3 min, comparable to that of parotidectomy under general anesthesia. No major complications occurred. Minor complications included three cases of temporary postoperative facial nerve weakness limited to 1-2 lower division branches. At most recent follow up (10 to 48 months), all patients were medically stable and disease free.

CONCLUSION

In carefully selected patients, parotidectomy under local anesthesia is a viable treatment alternative that can be offered to patients. Successful outcomes require preoperative counseling, meticulous technique, and close collaboration with anesthesia colleagues.