Superficial parotidectomy versus extracapsular dissection: literature review and search for a gold standard technique

Impact of Surgeon's Experience and Tumor's Nature in the Use of Intraoperative Facial Nerve Monitoring in Superficial Parotidectomy. Preliminary Results from a Single-Center Retrospective Analysis

To assess the effectiveness of intraoperative facial nerve monitoring (IFNM) compared to non-monitoring in the prevention of post-operative facial nerve palsy during superficial parotidectomy. Patients treated with curative intent for parotid gland tumors between January 2020 and January 2022 were included. The study population has been divided in 2 groups, based on IFNM: the group A included patients operated with IFNM, whilst group B was the non-monitoring group. A further classification focused on the pathologies and the surgeons' experience. The study group included 58 patients, 27 female and 31 male. The mean age was 45.7 yr (range 36-78). No statistical difference has been found in post-operative HB grade between group A and B. The analysis of patients affected by pleomorphic surface lobe adenomas of the parotid did not show a statistical difference in HB outcome (p > 0.05). The analysis of the effect of surgeons' experience in IFNM advantage did not show statistical difference for superficial parotid tumors. The results of the present study suggest that the use of IFNM during parotid surgery is not mandatory to preserve the VII nerve function, both in case of primary tumor and in case of recurrence, and even when surgery is performed by less experienced surgeon compared to those cases treated by a more experienced surgeon.

The extracapsular dissection technique in the management of benign tumours of the parotid gland: our experience in 194 patients

OBJECTIVE

The indications for and approaches to extracapsular dissection for parotid gland benign tumours are debated in the literature. This study retrospectively evaluates a single site's short- and long-term results with a standardised extracapsular dissection approach to benign parotid tumours.

METHODS

A retrospective review of a single institution's records identified cases with extracapsular dissection as the primary surgery for non-recurrent benign parotid tumours. A total of 194 eligible patients were identified (124 women and 70 men, age 47.75 ± 15.62 years). Pre-, intra- and post-surgical data were reviewed for complications and recurrences.

RESULTS

Histology reported pleomorphic adenoma in 165 patients, Warthin's tumour in 28 patients and both in one patient. Mean follow up was 36 ± 16 months (range, 12-84 months). The incidences of complications following extracapsular dissection were temporary (n = 13) and permanent (n = 0) facial nerve dysfunction, Frey's syndrome (n = 1)) and recurrences (n = 5). These rates align with prior literature.

CONCLUSION

This case series shows how a standardised approach to extracapsular dissection for benign parotid tumours yields favourable results, supporting a progressive change of strategy towards reduced invasiveness.

Surgical management of Warthin tumor: long-term follow-up of 224 patients from 2002 to 2018

PURPOSE

Warthin tumors (WT) are the second most common benign parotid gland neoplasms. They can occur as synchronous or metachronous lesions in 6-10% of cases. This study aims to compare the complication rate in 224 patients who underwent extracapsular dissection (ECD) or superficial parotidectomy (SP) for the treatment of a WT.

METHODS

This retrospective study was conducted at the Department of Maxillo-Facial Surgery at the University of Naples "Federico II" from February 2002 to December 2018 on a group of patients who underwent surgical treatment for WT. The type of surgical technique was chosen based on Quer's classification. The complications evaluated were facial nerve palsy, hematoma, Frey's syndrome, and bleeding.

RESULTS

A total of 224 patients treated from 2002 to 2018 for Warthin tumor were included in the study. Two hundred elven had solitary tumors (94.1%) and 13 had multicentric lesions (5.8%), of which 9 cases presented synchronous lesions and 4 cases presented metachronous lesions. Extracapsular dissection (ECD) was performed in 130 patients (58.3% of cases) and superficial parotidectomy (SP) in the other 94 (41.7% of cases).

CONCLUSIONS

We consider both surgical techniques as valid. In our opinion, it is essential to study each case based on Quer's Classification to obtain the best surgical outcome. Based on a lower observed rate of complications such as facial nerve palsy, Frey's syndrome, and bleeding, ECD seems to be the best option for the surgical treatment of Quer Class I lesions.

Extracapsular dissection versus total excision for benign submandibular gland tumors

INTRODUCTION

Benign submandibular gland tumors pose challenges in balancing treatment effectiveness and preserving gland function. This study aimed to compare gland-preserving surgery, extracapsular dissection (ECD), with total excision in managing these tumors, focusing on function preservation and recurrence rate.

METHODS

Fifty consecutive patients with treatment-naïve benign submandibular gland tumors were alternatively allocated to receive ECD (n = 25) or total excision (n = 25) without randomization procedures. Intraoperative findings, postsurgical complications, subjective satisfaction, and gland function were assessed. Follow-up data were collected for a median duration of 55 months (24-80 months) to monitor recurrences.

RESULTS

ECD demonstrated significant advantages, including shorter operation time, reduced bleeding, and preservation of the facial artery and vein (P < 0.05). Both groups exhibited acceptable postsurgical pain and taste sensations. Complications were minimal and similar between the two groups. ECD resulted in superior facial contour satisfaction (P = 0.030) and preserved gland function, as evidenced by salivary scintigraphy. No recurrences were observed in either group during the follow-up period.

CONCLUSIONS

ECD is a practical approach for benign submandibular gland tumors, offering favorable functional outcomes, reduced surgical morbidity, shorter operation times, and improved cosmetic results.

Selective Deep Lobe Parotidectomy vs Total Parotidectomy for Patients With Benign Deep Lobe Parotid Tumors

Importance

Limited literature exists on surgical outcomes after selective deep lobe parotidectomy (SDLP) with preservation of superficial lobe for patients with benign deep lobe tumors.

Objective

To compare the following factors for SDLP vs total parotidectomy for patients with benign tumors in the deep lobe: postoperative complications, including facial nerve paresis or paralysis, Frey syndrome, first bite syndrome, cosmetic defect, sialocele formation, and wound infection; and tumor control and recurrence.

Design, Setting, and Participants

This case series included 273 adults who underwent SDLP (n = 177) or total parotidectomy (n = 96) at a single tertiary care institution for benign parotid tumors located in the deep lobe or deep lobe and parapharynx from January 1, 2000, to December 31, 2020.

Exposure

Selective deep lobe parotidectomy vs total parotidectomy.

Main Outcomes and Measures

Incidence of postoperative complications and tumor recurrence.

Results

Among 273 patients (SDLP, 177 [65%]; 122 women [69%]; median age at surgery, 58 years [IQR, 46-67 years]; total parotidectomy, 96 [35%]; 57 women [59%]; median age at surgery, 59 years [IQR, 40-68 years]), the most common tumor was pleomorphic adenoma (SDLP, 128 of 177 [72%]; total parotidectomy, 62 of 96 [65%]). An abdominal dermal fat graft was less commonly performed for patients who underwent SDLP than those who underwent total parotidectomy (2 of 177 [1%] vs 20 of 96 [21%]; difference, -20% [95% CI, -28% to -11%]). The rate of great auricular nerve preservation was higher in the SDLP group than in the total parotidectomy group (84 of 102 [82%] vs 20 of 34 [59%]; difference, 24% [95% CI, 5%-42%]). No meaningful difference in length of hospital stay was found. The percentage of patients with House-Brackmann grade I immediately after surgery was 48% (85 of 177) in the SDLP group and 21% (20 of 96) in the total parotidectomy group (difference, 28% [95% CI, 16%-40%]). There were no clinically meaningful differences in rates of hematoma, sialocele, seroma, ear numbness, wound infection, or unplanned return to emergency department or operating room. The SDLP group reported a lower rate of Frey syndrome than the total parotidectomy group (1 of 137 [1%] vs 12 of 78 [15%]; difference, -15% [95% CI, -23% to -7%]), as well as a lower rate of facial contour defect (28 of 162 [17%] vs 25 of 84 [30%]; difference, -13% [95% CI, -24% to -1%]) and a higher rate of first bite syndrome (34 of 148 [23%] vs 7 of 78 [9%]; difference, 14% [95% CI, 5%-23%]). The percentage of patients with House-Brackmann grade I at their first follow-up visit was 67% (118 of 177) in the SDLP group compared with 49% (47 of 96) in the total parotidectomy group (difference, 17% [95% CI, 4%-30%]). There was no clinically meaningful difference in House-Brackmann grade after 1 year.

Conclusions and Relevance

Findings of this case series study suggest that SDLP can be considered an effective and even superior technique for management of benign tumors in the deep parotid lobe. Advantages associated with SDLP include reduction in need for reconstruction for facial contour defect and reduction in complications, such as immediate facial nerve weakness and Frey syndrome. The incidence of first bite syndrome was higher in the SDLP group. Tumor control was not compromised by SLDP.

Validation of indications for enucleation for benign parotid gland tumors

BACKGROUND

Enucleation has been reported as a minimally invasive surgery for Warthin's tumor (WT). However, the definite indications for enucleation have not been clarified.

METHODS

Enucleation was indicated by the following findings: findings of WT, cystic fluid, or benign leukocytes by fine-needle aspiration cytology; a well-margined and homogeneous pattern on imaging; and a tumor location in the tail or preauricular area of the parotid gland. We reviewed 552 cases treated with parotid gland surgery in our hospital.

RESULTS

A total of 108 tumors were treated with enucleation and included no malignant solid tumors or pleomorphic adenoma. Enucleation demonstrated low invasiveness and complication rates. Revision surgery for WT reappearance after enucleation was rare and showed minimal scarring, with a lower risk of facial weakness.

CONCLUSIONS

The indication criteria for enucleation were validated. Such enucleation is useful, as it is associated with minimal invasiveness, low complication rates, and safety in revision surgery.

Clinical outcomes and cost-effectiveness of superficial parotidectomy versus extracapsular dissection of the parotid gland: a single-centre retrospective study of 161 patients

Improvements in preoperative diagnostics and intraoperative techniques have made the surgical excision of benign parotid gland tumours less invasive. Extracapsular dissection (ECD) has become more popular in comparison to superficial parotidectomy (SP), the gold standard. Although clinical outcomes have been reported, reports on cost-effectiveness are limited. The aim of this retrospective study was to analyse the surgical outcomes and cost-effectiveness of ECD versus SP in benign parotid tumour surgery. A retrospective cohort of 161 patients treated between 2012 and 2020 was collected. Data concerning demographics, clinical outcomes, and cost-efficiency were recorded. Analysis of the 161 unilateral parotidectomy cases (59 SP, 102 ECD) showed a significantly longer operation time, anaesthesia time, and length of stay for SP patients (all P < 0.001). Regarding postoperative complications, transient facial nerve weakness (P < 0.001) and haematoma formation (P = 0.016) were more prevalent in the SP patients. The frequency of positive margins was lower for SP (P = 0.037). No case of recurrence was identified with either technique. ECD showed excellent clinical outcomes as well as a reduction in complications when compared to SP. ECD is a viable alternative for superficial benign parotid gland tumours after thorough preoperative clinical, pathological, and radiological examination. The reduction in operation, anaesthesia, and hospitalization times with ECD is likely to result in a gain in cost-effectiveness.

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.

Extracapsular dissection with a transparotid facial nerve dissection approach versus partial superficial parotidectomy for benign tumours in the tail of the parotid gland: a single-centre retrospective study of 89 patients

The aims of this study were (1) to evaluate the transparotid facial nerve dissection approach (TFND), in which the intraparotid cervicofacial or temporofacial division is identified first through a superficial lobe incision; and (2) to compare extracapsular dissection with a TFND (ECD-TFND) with partial superficial parotidectomy with a retrograde approach (PSP) for benign tumours in the tail of the parotid gland with respect to surgical outcomes. Eighty-nine patients underwent PSP or ECD-TFND for benign tumours in the tail of the parotid gland: 49 were treated surgically with PSP and 40 with ECD-TFND. The mean ( ± standard deviation) surgical time did not differ significantly between the groups: 64 ± 22.4 min for PSP and 59 ± 19.8 min for ECD-TFND (P = 0.302). There was a significant difference in sialocele: 18 (36.7%) patients in the PSP group and four (10%) in the ECD-TFND group (P = 0.002). There was also a significant difference in facial nerve injuries: temporary paralysis was observed in 13 (26.5%) patients in the PSP group and two (5%) in the ECD-TFND group (P = 0.007). It appears that TFND is a viable and safe approach when performing ECD for benign tumours in the tail of the parotid gland. ECD-TFND should be preferred over PSP for benign tumours in the tail of the parotid gland.

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.

Fine needle aspiration is a suitable diagnostic modality for parotid tumors but has important limitations.

Extracapsular dissection is safe and effective for small superficial tumors away from the facial nerve.

Nerve monitoring may reduce temporary facial weakness but does not replace robust surgical technique.

Outpatient parotidectomy is safe and feasible for appropriately selected patients.

Expression of cartilage oligomeric matrix protein (COMP) associates with capsular invasion in salivary gland pleomorphic adenoma

BACKGROUND

Accumulating evidence shows that pleomorphic adenoma (PA) exhibits a unique capsular invasion and with a crucial role in recurrence. This study was designed to explore RNA expression profiles in salivary gland PA in an attempt to further analyse genes associate with capsule invasion.

METHODS

We evaluated the expression profiles of 4 salivary gland PA patients by RNA-sequencing. The principal functions of the differentially expressed mRNAs (DEGs) were explored using GO and KEGG analysis. Then, RT-qPCR and correlation analyses were performed to verify the candidate DEGs in 59 PA patients, and immunohistochemical examinations were conducted to validate candidate DEGs. Finally, the COMP-related genes were screened using correlation and biological pathway enrichment analysis, and further validated by RT-qPCR.

RESULTS

A total of 974 DEGs were significantly upregulated and 1464 were downregulated (fold change ≥2.0; p < 0.05). Based on GO and KEGG analyses, extracellular matrix organization and the PI3K-Akt signaling pathway might play pivotal roles in the tumorigenesis of PA. 40 DEGs were screened and validated by RT-qPCR, 11 upregulated and 5 downregulated DEGs were consistent with the sequencing results. Cartilage oligomeric matrix protein (COMP) was identified to have a significant correlation with the capsular invasion of PA and expression of COMP in patients with invasive capsular PA was significantly stronger than PA. Finally, further results could reveal that 5 highest-scoring genes were screened as hub genes for COMP.

CONCLUSIONS

These findings suggested that COMP may be a prognostic target for PA and might contribute to its capsular invasion.

Extracapsular Dissection for Small Benign Tumors of Parotid Gland: A Case Report on Contemporary Technique

Salivary gland tumor looms as painless enlarging mass which may embrace in both major or minor glands. Pleomorphic adenoma (PA) accord about 40-70% of all salivary gland tumors, where Warthin tumor, basal cell adenoma (BCA), adenoid cystic carcinoma (ACC), and sebaceous tumors have a strong predilection for major salivary gland. However, polymorphous low-grade adenocarcinoma (PLGA) has a marked predilection for the minor salivary gland. We present a case of PA in a 26-year-old male patient that has been successfully managed by extracapsular dissection (ECD) without any post-operative complications.

Synchronous Ipsilateral Pleomorphic Adenomas of Parotid and Submandibular Glands: An Unusual Finding

A rare case of synchronous ipsilateral pleomorphic adenomas (PA) of the left parotid and submandibular glands is reported. Simultaneous multiple PA in major salivary glands are a very rare entity, and merely few cases of ipsilateral synchronous PA involving parotid and submandibular glands are reported in the literature. The case of a 40-year-old female with a six-year history of asymptomatic growing lesion in both left parotid and left submandibular regions is presented. Left superficial parotidectomy and left submandibular gland excision at the same surgery have been performed. The aim of this article is to highlight the importance of an accurate head and neck presurgery examination both clinically and radiologically, keeping in mind the possibility of multiple tumor location.

Prospective outcomes following drainless superficial parotidectomy with sternocleidomastoid flap reconstruction

Background

Patients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey’s syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement.

Methods

All patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010–2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement.

Results

Fifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient’s (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey’s Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery.

Conclusion

In the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.

Facial nerve monitoring during parotid gland surgery: a systematic review and meta-analysis

INTRODUCTION

Facial nerve injury remains the most severe complication of parotid gland surgery. However, the use of intraoperative facial nerve monitoring (IFNM) during parotid gland surgery among Otolaryngologist-Head and Neck Surgeons continues to be a matter of debate.

MATERIALS AND METHODS

A systematic review and meta-analysis of the literature was conducted including articles from 1970 to 2019 to try to determine the effectiveness of intraoperative facial nerve monitoring in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without intraoperative facial nerve monitoring.

RESULTS

Ten articles met inclusion criteria, with a total of 1069 patients included in the final meta-analysis. The incidence of immediate and permanent postoperative weakness following parotidectomy was significantly lower in the IFNM group compared to the unmonitored group (23.4% vs. 38.4%; p = 0.001) and (5.7% vs. 13.6%; p = 0.001) when all studies were included. However, when we analyze just prospective data, we are not able to find any significant difference.

CONCLUSION

Our study suggests that IFNM may decrease the risk of immediate post-operative and permanent facial nerve weakness in primary parotid gland surgery. However, due to the low evidence level, additional prospective-randomized trials are needed to determine if these results can be translated into improved surgical safety and improved patient satisfaction.