Extra-capsular dissection in benign parotid tumors

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.

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.

Minimal Margin Surgery and Intraoperative Neuromonitoring in Benign Parotid Gland Tumors: Retrospective Clinical Study

Extracapsular dissection (ECD) was introduced for the removal of superficial and small benign parotid tumors. According to a recent proposal, ECD is reserved for tumors that are 3 cm or less, mobile, and close to the parotid borders in cases of pleomorphic adenoma. The aim of the study is to evaluate the effectiveness of ECD for treatment of benign parotid tumors also in cases of tumors that were larger than 3 cm and deeper. All ECD for benign parotid neoplasms conducted between 2007 and 2017 were reviewed. The lesions included were limited to primary parotid tumors and categorized by Quer proposal. Facial nerve monitoring was used in all cases. Facial nerve palsy and local recurrences were assessed. The 88 ECD performed met inclusion criteria. The mean lesion size was 4.26 cm. Of the tumors, 68 were less than 3 cm in diameter and 20 were larger, 64 were superficial, and 24 were deep. The most common lesion types were pleomorphic adenoma (88.6%). There was no significant difference in complication rates between the size of tumor (p = 0.9) and location (p = 0.91). Our results suggest that extracapsular dissection could be considered an option for first-time diagnosed benign parotid tumors, even in cases of large dimensions and deep lobe involvement.

An update on extracapsular dissection for the management of parotid gland pleomorphic adenoma

Superficial parotidectomy has been the gold standard for surgical removal of benign mobile parotid gland tumours. The comparatively newer technique of extracapsular dissection, which involves careful dissection of the tumour itself without the need for formal gland excision, has gained popularity in recent years. Tumours can be removed via smaller incision, and the technique reduces the risk of Frey's syndrome (gustatory sweating) and hollowing at the site of surgery. The risk of facial nerve damage can also be lower with extracapsular dissection. If done carefully, the incidence of tumour recurrence, particularly for pleomorphic adenomas, is comparable with formal parotidectomy. We provide a brief update overview of the current evidence for extracapsular dissection in the treatment of benign parotid tumours and include several meta-analyses which provide evidence for the safety of the technique. We have also included our audited results of over 100 recent extracapsular dissections, with 0% incidence of permanent facial nerve weakness, reported Frey's syndrome and recurrence rates over the last 5 years.

Effective surgical management of anterior tumors of the parotid gland: Main trunk method vs. peripheral Smethod

OBJECTIVE

Several surgical procedures have been proposed for tumors in the anterior parotid gland. Although the standard approach to other parotid tumors is generally also used for anterior tumors, handling of the facial nerve has not been addressed in any previous reports.

METHODS

A total of 654 patients with benign parotid tumors who underwent surgery in our department were classified into anterior (AT), middle (MT), and posterior tumor (PT) groups according to tumor location. Clinical characteristics, histopathological types, and frequency of postoperative transient facial palsy were examined. In the AT group, two surgical methods were compared, which were the main trunk method (MTM) and the peripheral method (PM).

RESULTS

172 patients were included in the AT group, 175 in the MT group, and 307 in the PT group. The AT group showed significant female predominance and a higher percentage of deep lobe tumors than the PT group. There was no significant difference in the rate of postoperative transient facial palsy among the AT (MTM), MT, and PT groups. The PM had a significantly shorter operating time and lower rate of transient facial palsy than the MTM.

CONCLUSION

The PM for AT was considered a useful surgical method from the standpoints of postoperative complications and operating time. In the PM, a wide operating field made identification of the facial nerve easier.

Extracapsular Dissection in Pleomorphic Adenomas of the Parotid Gland: Results After 13 Years of Follow-up

OBJECTIVES/HYPOTHESIS

To assess long-term results after the treatment of parotid pleomorphic adenomas (PPAs) using different surgical techniques and focusing on recurrence rates and the risk of adverse effects.

STUDY DESIGN

Retrospective analysis.

METHODS

Retrospective analysis of 182 patients treated exclusively for PPAs at a tertiary referral center between 2000 and 2004. Thorough follow-up examinations over a mean period of 13 years were possible in 53.8% (n = 98/182). Tumors were categorized according to the European Salivary Gland Society (ESGS) system to improve the comparison of outcomes. After different surgical resection strategies, recurrence rates, postoperative facial nerve paresis (FNP), and incidence of Frey's syndrome were assessed. The follow-up period included clinical examinations and imaging of every patient in the treating department.

RESULTS

Of 182 patients, extracapsular dissection (ED) was performed in 29.7%, and other surgical modalities (OSMs), including facial nerve dissection, in 70.3%. After the long-term follow-up, 98% of all the patients (n = 96/98) were recurrence free. When recurrence rates were compared, no significant differences were noted (P < .331). ED resulted in significantly lower FNP rates compared to OSMs (P < .001). FNP rates significantly increased with size and location of the tumors according to ESGS categories (temporary and permanent FNP, P = .04). Surgical invasiveness corresponded to a significant increase in the incidence of Frey's syndrome (P < .001).

CONCLUSIONS

ED was associated with the lowest complication rates, but not with a higher risk of recurrence, when compared with OSM in the long-term course. As ED can be performed in the majority of PPAs, it can be regarded as the treatment of choice whenever possible.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E445-E451, 2021.

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

Benign parotid tumours usually present as a slow-growing, asymptomatic mass in the pre-auricular region. Although they are uncommon, surgical excision is the mainstay of treatment due to the risk of malignant transformation in some benign tumours. Surgical techniques have evolved over the years, with superficial parotidectomy and extracapsular dissection being the current procedures of choice. There is currently no gold standard, and it remains unclear which surgical modality is the superior option. A literature review was performed in relation to the relative merits of each technique and to evaluate the reasons underpinning the ongoing debate. A total of 16 papers comparing the main clinical outcomes of the procedures were critically reviewed using the PRISMA protocol. Overall, extracapsular dissection indicated a reduced recurrence rate, facial nerve paralysis, Frey syndrome, and operation time. The superior outcomes following extracapsular dissection could be attributed to the less radical nature of the procedure. However, there were various limitations identified within the review that may have affected the results. Selection bias was the most significant, with patients assigned to the different procedures depending on the tumour size and location. Consequently, the debate continues as to what constitutes the gold standard of care for benign parotid tumours.

Parotid pleomorphic adenomas: Factors influencing surgical techniques, morbidity, and long-term outcome relative to the new ESGS classification in a retrospective study

PURPOSE

To assess long-term results after treatment of parotid pleomorphic adenomas (PPAs) with different surgical techniques, standardized according to the European Salivary Gland Society (ESGS) classification system.

METHODS

We analyzed ESGS categories, occurrence of facial nerve paresis (FNP), Frey's syndrome, histopathology, and recurrences. Surgical modalities were compared, differentiating techniques with and without facial nerve dissection. A strict protocol ensured a postoperative follow-up-period of more than 7 years.

RESULTS

205 patients were included. A complete follow-up was possible in 138 patients, 77 of whom underwent extracapsular dissection (ED) and 61 of whom had other surgical modalities (OSMs). ESGS categories correlated with the extent of surgery, significantly with the risk for FNP and Frey's syndrome, but not with recurrences. Recurrences did not differ significantly between ED and OSMs, whereas the risks for FNP (p < 0.001 each) and Frey's syndrome (p = 0.000) were significantly higher after OSMs in comparison with ED. Young women with a stroma-rich (myxoid) tumor subtype appear to have the greatest risk for recurrences.

CONCLUSION

ED is the treatment of choice for PPAs, if possible, resulting in similar recurrence rates but significantly fewer comorbidities in comparison with more extensive surgery. After the treatment of PPAs, a long-term follow-up is needed, including imaging.

Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients

We evaluated the aesthetic outcomes in 11 young patients (mean (range) age 21.7 (16-28) years) who had endoscopically assisted extracapsular dissection of benign pleomorphic adenomas of the parotid gland through a postauricular sulcus approach. The tumours varied in size from 1.5×1.0cm to 2.5×2.0cm, and all were removed completely without rupture. The cosmetic result was excellent in 10 patients and good in one. Patients were followed up for eight to 40 months, and there was no recurrence. The technique is simple and feasible, and it achieves excellent aesthetic results in young patients.

Contemporary management of benign parotid tumours - the increasing evidence for extracapsular dissection

Benign parotid tumours have historically often been managed surgically by superficial parotidectomy. While this approach usually gives a generous cuff of surrounding normal parotid tissue to increase tumour margins, it requires a much larger incision than the increasingly used extracapsular dissection (ECD) technique. Furthermore, superficial parotidectomy can result in marked facial hollowing, Frey syndrome and an increased risk of both temporary and permanent facial nerve weakness. ECD has been popularised as a safe alternative to parotidectomy primarily for the removal of mobile, benign parotid tumours with safe outcomes and reduced risk to the facial nerve. In this article, we review the growing body of evidence for ECD and include our own experience confirming the move away from superficial parotidectomy in contemporary practice for the treatment of benign parotid tumours.

Charcoal Suspension Tattoo: A New Technique for Intraoperative Detection of Small Tumors of the Parotid Gland

OBJECTIVE

The current surgical trend in the treatment of pleomorphic adenomas of the parotid gland is to limit the extent of resection. This raises the need to correctly identify the mass within the normal parenchyma so as to avoid dissecting the entire superficial lobe of the gland. We describe ultrasound-guided tattooing as a technique to facilitate identification and excision of parotid pleomorphic adenomas.

METHODS

We reviewed 23 consecutive patients with pleomorphic adenoma of the parotid gland. All patients underwent ultrasound-guided tattooing of the lesions with a charcoal suspension. Baseline tumor and patients' characteristics, major and minor complications, and subjective tolerance to the procedure were recorded. We assessed the number of intralesionally marked masses and the percentage of intraoperatively detected marked lesions.

RESULTS

The injection was well tolerated. No major complications were recorded. In 2 cases (9%), a transient increase in lesion size was observed. No other minor complications were encountered. Charcoal was found inside the tumor in 19 cases (83%). In 4 cases (17%), it was found in the tissues above the lesion. Twenty-three lesions were intraoperatively detected (100%) and dissected.

CONCLUSION

Charcoal suspension tattooing is safe and well tolerated for the detection of small pleomorphic adenomas during parotid surgery.

PRISMA-Extracapsular Dissection Versus Superficial Parotidectomy in Treatment of Benign Parotid Tumors: Evidence From 3194 Patients

Benign parotid tumor is one of the most common neoplasms in head and neck region. Its therapeutic methods have been debatable topics over the past 100 years. Recently, some surgeons suggest that extracapsular dissection (ECD) instead of superficial parotidectomy (SP) for treatment of benign parotid tumor. This study aimed to compare ECD with SP in the treatment of benign parotid tumors by a meta-analysis.We searched Cochrane Library, PubMed, Embase, Ovid, and Web of Science databases on February 14, 2015 for studies that assessed clinical outcomes of SP and ECD as surgical techniques for the management of benign parotid tumors. Outcome data were evaluated by pooled risk ratio (RR) and corresponding 95% confidence interval (CI).After serious scrutiny, a total of 14 cohort studies with 3194 patients were included in this meta-analysis. The pooled RR revealed that there were no significant difference in tumor recurrence rate between ECD and SP (fixed-effect model: RR = 0.71, 95% CI = 0.40-1.27, P = 0.249; random-effect model: RR = 0.67, 95% CI = 0.38-1.23, P = 0.197). However, there were significantly lower incidences of transient facial nerve dysfunction (FND), permanent FND, and Frey's syndrome in patients of ECD group compared with SP group.ECD might be a good choice in treatment of the benign parotid tumor that were mobile, small, located in superficial lobe and without adhesion to facial nerve; ECD should be performed by the experienced surgeons with ability of dissection facial nerve, who should perform SP if tumor is found adhere to facial nerve during an operation; and a multicenter randomized control trial study is necessary to decide the optimal treatment of benign parotid tumor.

Use of scopolamine patches in patients treated with parotidectomy

The antimuscarinic effect of scopolamine causes a reduction of salivary secretion, so it can be used successfully in postoperative parotid surgery. The aim of this article was to demonstrate the efficiency of postoperative use of scopolamine transdermal patch in reduction of complications due to the presence of saliva in the surgical spaces.

Pleomorphic adenoma of the parotid: extracapsular dissection compared with superficial parotidectomy--a 10-year retrospective cohort study

The purpose of this study was to investigate the complication rates and effectiveness of extracapsular dissection compared with superficial parotidectomy for pleomorphic adenomas of the parotid gland from 2002 to 2012. The authors carried out a retrospective cohort study of 198 patients with pleomorphic adenomas of the parotid gland. Extracapsular dissection (ED) or superficial parotidectomy (SP) was performed. The recurrence rate and complications of the two surgical techniques were measured with a univariate analysis of each variable using the appropriate statistical analysis (chi-squared test or t-test). A total of 198 patients were enrolled between January 2003 and December 2012. The study included 97 females (48.99%) and 101 males (51.01%) whose mean age was 50.97 years (range 14–75). The type of surgery performed was ED in 153 patients (77.27%, 80 males and 73 females) and SP in 45 patients (22.73%, 21 males and 24 females). The mean follow-up time was 61.02 +/− 4.9 months for the patients treated with ED and 66.4 +/− 4.5 months for the patients treated with SP. Transient facial nerve injury and facial paralysis were significantly more frequent after SP than after ED (P = 0.001 and P = 0.065, resp.). No significant differences in capsular rupture, recurrence, and salivary fistula were observed after SP or ED: 2.2% versus 3.9%, 2.2% versus 3.3%, and 2.2% versus 0.65%, respectively. Extracapsular dissection may be considered the treatment of choice for pleomorphic adenomas located in the superficial portion of the parotid gland because this technique showed similar effectiveness and fewer side effects than superficial parotidectomy.

Etiology and management of recurrent parotid pleomorphic adenoma

The objective of this review study was to encompass the relevant literature and current best practice options for this challenging, sometimes incurable problem. The source of the data was Ovid MEDLINE from 1946 to 2014. Review methods consisted of articles with clinical correlates. The most important cause of recurrence is enucleation with rupture and incomplete tumor excision at operation. Incomplete pseudocapsule, extracapsular extension, pseudopods of pleomorphic adenoma tissue, and satellite pleomorphic beyond the pseudocapsule are also likely linked to recurrent pleomorphic adenoma. Most recurrent pleomorphic adenoma are multinodular. Magnetic resonance imaging is the imaging study of choice for recurrent pleomorphic adenoma. Nerve integrity monitoring may reduce morbidity for recurrent pleomorphic adenoma. Treatment of recurrent pleomorphic adenoma must be individualized. Total parotidectomy, given the multicentricity of recurrent pleomorphic adenoma, is appropriate in many patients, but may be inadequate to control recurrent pleomorphic. There is accumulating evidence from retrospective series that postoperative radiation therapy results in significantly better local control.

Correlations between the clinical, histological and neurophysiological examinations in patients before and after parotid gland tumor surgery: verification of facial nerve transmission

Parotid gland tumor surgery sometimes leads to facial nerve paralysis. Malignant more than benign tumors determine nerve function preoperatively, while postoperative observations based on clinical, histological and neurophysiological studies have not been reported in detail. The aims of this pilot study were evaluation and correlations of histological properties of tumor (its size and location) and clinical and neurophysiological assessment of facial nerve function pre- and post-operatively (1 and 6 months). Comparative studies included 17 patients with benign (n = 13) and malignant (n = 4) tumors. Clinical assessment was based on House-Brackmann scale (H-B), neurophysiological diagnostics included facial electroneurography [ENG, compound muscle action potential (CMAP)], mimetic muscle electromyography (EMG) and blink-reflex examinations (BR). Mainly grade I of H-B was recorded both pre- (n = 13) and post-operatively (n = 12) in patients with small (1.5-2.4 cm) benign tumors located in superficial lobes. Patients with medium size (2.5-3.4 cm) malignant tumors in both lobes were scored at grade I (n = 2) and III (n = 2) pre- and mainly VI (n = 4) post-operatively. CMAP amplitudes after stimulation of mandibular marginal branch were reduced at about 25 % in patients with benign tumors after surgery. In the cases of malignant tumors CMAPs were not recorded following stimulation of any branch. A similar trend was found for BR results. H-B and ENG results revealed positive correlations between the type of tumor and surgery with facial nerve function. Neurophysiological studies detected clinically silent facial nerve neuropathy of mandibular marginal branch in postoperative period. Needle EMG, ENG and BR examinations allow for the evaluation of face muscles reinnervation and facial nerve regeneration.

Recurrent Pleomorphic Adenoma of the Parotid Gland

Objective

To determine the benefit to postoperative facial function of intraoperative facial nerve monitoring (IFNM) during recurrent pleomorphic adenoma (RPA) parotid surgery.

Study Design

Cohort study with planned data collection.

Setting

Chinese PLA General Hospital.

Subjects and Methods

Fifty-eight RPA parotidectomies were performed between 2004 and 2012. Recurrence was confirmed by histopathologic examination. None of the patients had preoperative facial palsy. Electromyography-based IFNM was used in 28 patients; 30 patients were unmonitored. The durations of surgery and the severity of postoperative facial nerve palsy were compared between the 2 groups.

Results

There were no significant differences between the 2 groups in the incidence of immediate or permanent facial paralysis after RPA parotidectomy ( P = .95 and P = .36, respectively). However, the differences in the average duration of surgery and the severity of postoperative facial nerve palsy after total parotidectomy or wide resection were significant ( P < .01 and P = .01, respectively). In contrast, these differences were not significant after superficial parotidectomies ( P = .43 and P = .49, respectively). The average recovery time of temporary facial nerve paralysis was significantly shorter in the monitored group compared with the unmonitored group, independent of surgical technique ( P < .01).

Conclusion

The use of IFNM during total or wide resection RPA parotidectomy reduced the duration of surgery and the incidence of postoperative facial paralysis and enhanced recovery. However, there was little impact on facial nerve outcomes when IFNM was used during superficial RPA parotidectomy.