Endoscope-assisted parotidectomy for benign parotid tumors

Endoscope-Assisted Hairline Approach for Head and Neck Masses: A Review

Conventional surgery through a transcervical incision is indicated for the treatment of certain tumors in the head and neck. However, this method can cause multiple problems, including scarring and cosmetic concerns. The endoscope-assisted hairline approach, which serves as an alternative to conventional surgical procedures, is gaining popularity due to its excellent cosmetic and functional outcomes. However, given the anatomical complexity involved, the endoscope-assisted hairline technique is not frequently employed in head and neck surgery. The evolution of the hairline surgical approach has been influenced by changes in disease conditions and recent advances in surgical tools. This review article discusses the use of endoscope-assisted hairline approaches in the resection of head and neck masses, focusing on the surgical procedure and postoperative clinical outcomes.

Endoscope-Assisted Resection of Benign Parotid Tumors via Concealed Post-Auricular Sulcus Incision

OBJECTIVES

To investigate the feasibility, safety, and effectiveness of endoscopic-assisted resection of benign parotid tumors via concealed post-auricular sulcus incision.

METHODS

Between October 2019 and March 2021, eligible patients with diagnosed benign parotid tumors were prospectively included and randomly assigned to two groups: the endoscope-assisted post-auricular sulcus incision group (endoscope group) and the conventional Blair "S" incision group (conventional group).

RESULTS

A total of 45 patients were finally included, including 24 subjects in the endoscope group and 21 subjects in the conventional group. No obvious differences were observed in basic information between these two groups of patients. The surgical incision length in endoscope group patients was 4.0 ± 0.4 cm, which was significantly shorter than that in conventional group patients, 10.3 ± 1.6 cm (p < 0.001). The total intraoperative blood loss, the first post-operative day drainage volume, the total post-operative drainage volume, and the total drainage days were all significantly lower in endoscope group patients than in conventional group patients (all p < 0.05). Among 3 months follow-ups, no local recurrence or residual tumor were found in both groups of patients, and there were none of them had permanent facial paralysis or parotid fistula. The self-evaluated appearance satisfaction VAS scores of endoscope group patients were all 0, which was significantly lower than that of conventional group patients, 4.7 ± 1.6 (p < 0.001).

CONCLUSION

Compared with the conventional Blair "S" incision surgery, the endoscope-assisted resection of the benign parotid tumors via concealed post-auricular sulcus incision was safe and effective and showed advantages of faster recovery and better self-assessments of appearance satisfaction.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:133-138, 2023.

Endoscopic and Robotic Parotidectomy for the Treatment of Parotid Tumors: A Systematic Review and Meta-Analysis

Background

The goal of this review was to introduce endoscopic/robotic parotidectomy (EP/RP) and compare EP/RP against conventional parotidectomy (CP) regarding the intraoperative and postoperative parameters in the treatment of parotid tumors.

Methods

A systematic literature search of medical databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) was performed from inception to November 2020 to generate relevant studies.

Results

A total of 13 eligible studies (572 patients) were included for systematic review, and 7 out of 13 comparable studies for the quantitative synthesis of outcomes. Patients who underwent EP were characterized by less intraoperative bleeding volume, shorter incision length, and higher satisfaction postoperatively (WMD, 95% CI, -42.80; - 58.23 to -27.37; p < 0.01; WMD, 95% CI, -5.64; -7.88 to -3.39; p < 0.01; SMD, 95% CI, 1.88; 1.46 to 2.31; p < 0.01, respectively). However, operative time and risk of facial palsy exhibited no significant differences (WMD, 95% CI, -11.17; -26.71 to 4.34; p = 0.16; OR, 95% CI,0.71; 0.39 to 1.32; p = 0.28, respectively).

Conclusions

Our findings suggest that the current evidence does not adequately support EP is equally safe and effective as CP. In certain selected cases, endoscopic technology has its unique advantages. For patients with strong cosmetic needs, endoscopic or robotic techniques may be an alternative through adequate preoperative evaluations.

Systematic Review Registration

International Prospective Register of Systematic Reviews, identifier CRD42020210299.

[Comparison of endoscopic versus conventional surgery for benign parotid tumor: a metaanalysis]

To assess the efficacy and safety of endoscopic versus conventional surgery for benign parotid tumor. We searched the electronic databases including PubMed, Embase, Web of Science, CNKI and Wanfang Data for studies published before January, 2021. A meta-analysis was performed using Rev Man 5.3 software. We retrieved 8 eligible studies involving a total of 532 patients, and 4 of the studies were RCT. The results of meta-analysis showed that endoscopic surgery was better than conventional surgery in terms of incision length (WMD=- 5.73; 95% CI: - 6.84--4.62), intraoperative bleeding volume (WMD=-34.50; 95% CI: -49.09--19.91), postoperative drainage volume (WMD=- 21.72; 95% CI: - 29.31--14.12), subjective satisfaction with incision scar(WMD=2.23; 95%CI: 1.11-3.34), and temporary facial paresis (OR=0.37; 95%CI: 0.17-0.78). There were no significant differences in the operation time, salivary fistula, Frey's syndrome or tumor recurrence between the two groups. For treatment of benign parotid tumor, endoscopic surgery is a safe surgical procedure and is superior to conventional surgery in terms of incision length, operative bleeding volume, postoperative drainage volume, subjective satisfaction with incision scar, and temporary facial paresis.

Feasibility and advantages of endoscope-assisted parotidectomy: a systematic review and meta-analysis

The object of this paper was to explore the feasibility and advantages of endoscope-assisted parotid tumour resection. Three databases (PubMed, Web of Science, and Cochrane) were used to search for all related randomised controlled trials or controlled trials (up to November 2019). The key parameters for assessment included 'Endoscope', 'Endoscopes', 'Cancer of Parotid', and 'Parotid Cancer'. To evaluate the feasibility and advantages of endoscope-assisted resection of parotid tumours, the data for each parameter were pooled, based on patients who received endoscope-assisted surgery and those who received conventional surgery. This meta-analysis included seven studies, involving 170 patients in the endoscopy group and 270 patients in the control group. The analysis using the pooled data showed that there were no significant differences in the operating times between the two groups; however, the endoscopy group had significantly shorter incisions and less intraoperative bleeding. In addition, the patients who received endoscope-assisted surgery had lower incidences of temporary facial paralysis and Frey's syndrome after surgery. Patients in the endoscopy group had greater postoperative satisfaction. Endoscope-assisted parotid tumour resection results in only a small, concealed incision wound and fewer postoperative complications. Therefore, it is promising for the surgical treatment of parotid tumours.

Parotidectomy via Individualized Mini-Blair Incision

BACKGROUND

The modified Blair incision is the standard facial incision for the vast majority of parotid gland lesions. We utilize three types of incisions: "classic mini-Blair" for parotid body tumors, "cervical mini-Blair" for parotid tail tumors, and "vertical mini-Blair" for anterior parotid tumors. In this study, we describe the surgical and esthetic outcomes of these individually tailored incisions.

METHODS

Patients undergoing parotidectomy between 2011 and 2013 were included. The surgical outcomes and patients' satisfaction were assessed.

RESULTS

Of 122 patients, 89 were included. All patients completed a questionnaire assessing the postoperative course and patients' satisfaction regarding the surgery in general and the scar in particular. Among these patients, 78 (87%) had a benign pathology and 11 (13%) had malignant tumors. The tumors were located at the parotid body in 57 patients (64%), at the parotid tail in 19 (21%), at the deep lobe in 8 (9%), and at the anterior parotid gland in 5 (6%). All tumors were removed successfully with negative margins on pathology. No inadvertent permanent facial nerve paralysis occurred. The median operation time was 72 min (23-211). The average patient scores of satisfaction with the surgical scar and with the surgery were 9.54 and 9.72, respectively.

CONCLUSIONS

Individualized mini-Blair incision is feasible for benign as well as selected malignant parotid tumors.

Sternocleidomastoid Muscle Flap after Parotidectomy

Introduction Most patients after either superficial or total parotidectomy develop facial deformity and Frey syndrome, which leads to a significant degree of patient dissatisfaction.

Objective Assess the functional outcome and esthetic results of the superiorly based sternocleidomastoid muscle (SCM) flap after superficial or total parotidectomy.

Methods A prospective cohort study for 11 patients subjected to parotidectomy using a partial-thickness superiorly based SCM flap. The functional outcome (Frey syndrome, facial nerve involvement, and ear lobule sensation) and the esthetic results were evaluated subjectively and objectively.

Results Facial nerve palsy occurred in 5 cases (45%), and all of them recovered completely within 6 months. The Minor starch iodine test was positive in 3 patients (27%), although only 1 (9%) subjectively complained of gustatory sweating. The designed visual analog score completed by the patients themselves ranged from 0 to 3 with a mean of 1.55 ± 0.93; the scores from the blinded evaluators ranged from 1 to 3 with a mean 1.64 ± 0.67.

Conclusion The partial-thickness superiorly based SCM flap offers a reasonable cosmetic option for reconstruction following either superficial or total parotidectomy by improving the facial deformity. The flap also lowers the incidence of Frey syndrome objectively and subjectively with no reported hazard of the spinal accessory nerve.

Parotid surgery for benign tumours

PURPOSE

The majority of parotid tumours are benign, making parotid surgery a compromise between adequate tumour excision and preservation of function and facial harmony. Besides the traditional superficial or total parotidectomy, less invasive techniques have been described with similar recurrent rates. The aim of this review is to assess the evidence in the published literature and to summarise the advantages and disadvantages of the available techniques.

METHODS

A systematic search in Pubmed for studies on surgery of benign parotid tumours (BPTs) published between January 2000 and January 2012 was conducted. Case series with a clear description of the surgical technique and a minimum number of 10 patients were included.

RESULTS

Four hundred sixty-three articles were found, 49 abstracts reviewed and 37 case series were selected for this review. The surgical techniques for benign parotid tumours can largely be grouped into facial nerve dissecting (superficial parotidectomy, partial superficial parotidectomy and total parotidectomy) and non-nerve dissecting techniques (extracapsular dissection). With all of the currently used techniques, a low recurrence (<3 %) with a low incidence of permanent facial nerve morbidity (0.2-4 %) can be achieved. The tumour-facial nerve interface and pseudopodia are areas at risk for positive margins.

CONCLUSION

There is currently no agreement in the literature about the extent of surgery for BPTs to obtain an adequate margin. The tumour nerve interface is the predetermined area at risk for tumour spillage and positive margin. A prolonged follow-up is recommended. Further long-term randomised clinical trials are required to address the question of the extent of the excision in benign parotid surgery.

An objective assessment of proximal and distal facial nerve exploration during superficial parotidectomy

AIM

This study was undertaken to compare the proximal and distal facial nerve exploration approach during superficial parotidectomy.

MATERIALS AND METHODS

A retrospective analysis of patients who underwent superficial parotidectomy at our center was conducted. Cases were divided into those who underwent superficial parotidectomy using distal facial nerve exploration and those who underwent standard proximal facial nerve exploration. Statistical comparisons of intraoperative blood loss and margin status (negative, focally, positive) were conducted between these two approaches.

RESULTS

A total of 39 patients underwent superficial parotidectomy at our center between 2008 and 2010. The technique used in most of the cases was conventional proximal nerve exploration technique (29 cases). Distal exploration of the buccal branch was undertaken only in 10 cases, on account of difficulty in locating the main trunk intraoperatively due to the presence of postinflammatory fibrosis. The average patient age was 48 years with a female preponderance (67%). Both the techniques consumed almost same average operative time (2.4 hours) and average intraoperative blood loss (68.0 cc vs 25.4 cc) was more in the cases where proximal nerve exploration was resorted (S.E (d) = 0.89). No significant difference in surgical margin status was noticed between the two techniques (P > 0.05).

CONCLUSION

Both the techniques are efficient without compromising the surgical margins, but the average intraoperative blood loss is less in distal facial nerve exploration technique.

Proximal and distal Facial nerve exploration during superficial parotidectomy

One of the most technique sensitive surgeries in the maxillofacial region is the parotid gland surgery owing to the close relation between the gland and the extra-cranial course of facial nerve. Facial nerve is generally located by means of a proximal surgical identification technique aimed at identifying the facial nerve at its point of exit from the stylomastoid foramen to its entry into the posteromedial surface of parotid gland. There are reports in the literature on distal nerve identification techniques, either as a choice or in cases where proximal nerve identification is difficult. The present report deals with personal clinical experience, describing both the techniques for detection of the facial nerve in 17 cases reported. The technique mainly chosen was conventional proximal nerve identification technique in 16 cases. Distal exploration of the buccal branch was undertaken only in one case, on account of difficulty in locating the main trunk intraoperatively, due to the presence of a post inflammatory fibrosis. The decision to resort to the identification of the buccal nerve is supported by the regular course and adequate size of this branch of facial nerve in its peripheral area co-located with stenson's duct, which enable it to be easily identified during surgery.

Endoscopic resection of the submandibular gland via a hairline incision: a new surgical approach

OBJECTIVES/HYPOTHESIS

Submandibular gland excision is traditionally performed by the transcervical approach. To avoid or reduce visible scarring and nerve injury, diverse innovative surgical trials have been reported. Here we report a patient who had an endoscopic submandibular gland resection via a hairline incision.

METHODS

A 36-year-old woman presented with a right submandibular gland tumor that was found on a routine check-up. The submandibular gland was resected under endoscopic assistance via a posterior hairline incision using an ultrasonic scalpel.

RESULTS

The resection was successful, causing no acute complications, such as neural injury, hematoma, or seroma formation. The incision scar healed with an excellent cosmetic result.

CONCLUSIONS

Endoscopic submandibular gland resection via a hairline incision was feasible and resulted in an excellent surgical and cosmetic outcome. Laryngoscope, 2010.

Endoscope-assisted partial-superficial parotidectomy through two small skin incisions

CONCLUSION

Endoscope-assisted partial-superficial parotidectomy is a feasible method for treatment of benign parotid superficial lobe tumors located at the anterior or the inferior of the auricular lobule. The main advantage of this procedure is that the small operative scar resulted in improved cosmetic results.

OBJECTIVES

This study evaluated the feasibility of endoscope-assisted partial parotidectomy through two small skin incisions.

PATIENTS AND METHODS

Thirty cases with benign parotid superficial lobe tumors with a diameter < 30 mm located at the anterior or the inferior of the auricular lobule underwent endoscope-assisted partial-superficial parotidectomy via retrograde approach through two small skin incisions.

RESULTS

All 30 operations were successfully performed endoscopically. All the patients were satisfied with the cosmetic results. Only three patients had transient facial paresis and recovered in 1-2 months. The endoscopic surgery lasted for 106.48+/-12.62 min. There was no tumor recurrence during the follow-up after 26-50 months.

A comparison between endoscope-assisted partial parotidectomy and conventional partial parotidectomy

OBJECTIVE: To report the feasibility of endoscope-assisted parotidectomy with an ultrasonic scalpel.

STUDY DESIGN: Randomized clinical trial.

SUBJECTS AND METHODS: A total of 38 patients were randomly assigned to conventional (20 patients) or endoscope-assisted (18 patients) partial parotidectomy. Via retrograde approach, endoscopic and surgical instruments were inserted through two 20- to 25-mm incisions (retromandibular and postauricular).

RESULTS: The endoscopic surgery lasted for 108.61 ± 11.86 minutes and the bleeding volume was significantly lower than in the conventional group. All 18 patients were satisfied with their cosmetic results; 14 patients (65%) were satisfied with the great auricular nerve preservation; only one patient had temporary facial paresis and salivary fistula. There was no tumor recurrence in both groups during the follow-up after 26 to 40 months) the endoscope-assisted parotidectomy group (median 30 months, range 26–40 months) and conventional group (median 32 months, range 26–40 months).

CONCLUSION: Endoscope-assisted parotidectomy is a feasible technique. This procedure may serve as an alternative approach that allows a smaller incision.

Minimally Invasive Endoscope-Assisted Parotidectomy: A New Approach

OBJECTIVE

To evaluate the benefits of a new approach, endoscopic parotidectomy through a postauricular skin incision by using an ultrasonically activated scalpel.

STUDY DESIGN

An investigation of the outcome of endoscopic parotidectomy at a tertiary referral medical center.

METHODS

Fourteen operations for selected patients presenting with benign parotid tail disease were performed via minimally invasive endoscopic resection by a single surgeon (MK Chen).

RESULTS

All 14 operations were successfully performed endoscopically, and no conversions to conventional open resection were necessary. The procedures lasted 60 to 160 minutes. Two patients had transient grade II facial paresis. The scars were almost invisible due to their concealed location behind the ear.

CONCLUSIONS

Minimally invasive endoscope-assisted parotidectomy is a feasible method for treatment of benign lesions located in the parotid tail. The main advantage of this procedure is that the small operative scar is concealed in the postauricular area resulting in improved cosmetic results.

Endoscope-assisted submandibular sialoadenectomy: a pilot study

PURPOSE

To describe an endoscopic technique for submandibular sialoadenectomy in humans, as well as the equipment, instrumentation, and pertinent anatomy.

MATERIALS AND METHODS

Six submandibular sialoadenectomies were carried out in 5 patients (3 women, 2 men; mean age, 26.6 years; range, 16 to 42 years) via a 15 to 20 mm neck incision for insertion of the endoscopic camera and surgical instruments.

RESULTS

All operations were successful without conversion to an open surgery. Operative time was 20 to 120 minutes (mean, 65 minutes). All patients were discharged the day after surgery. There were no postoperative complications (hematoma, nerve injury, infection). All patients experienced a mild degree of edema, which had resolved totally at the 6-month follow-up visit. All patients were satisfied with the outcome and especially the cosmetic result.

CONCLUSIONS

Absence of extensive scars, nontraumatic dissection, and magnification of anatomic structures are the most obvious advantages of this innovative technique.

Submandibular gland endoscopic resection: a cadaveric study

Recent advancement of head and neck surgery has been marked by the development of endoscopic and video-assisted minimally invasive surgery. This study reports the feasibility of endoscopic submandibular gland resection in human cadavers. Twelve submandibular gland resections were performed in six human cadavers. A 30 degrees angle endoscope and conventional surgical instruments were inserted through two 15 mm submandibular incisions. Dissection was carried out bluntly with scissors in an avascular plane superficial to the gland. No insufflation was needed since transcutaneous sutures lead to effective retraction. Facial vessels, the lingual nerve and Wharton's duct were identified and protected. Vascular ligatures were performed using surgical miniclips. After the procedure, an open submandibular dissection was performed to control the integrity of the anatomical structures. In all cases, the resection of the submandibular gland was successful without the need for an additional incision. Injuries of the facial artery and lingual nerve occurred when the procedure was carried out initially. The operative time decreased with training, from 120 min for the first cases to 35 min for the later ones. In conclusion, endoscopic submandibular gland resection is possible without major difficulty. Training and experience reduce the operative time and the complication rate.

Endoscope-assisted management of varicose veins in the posterior thigh, popliteal fossa, and calf area

Varicose veins of the posterior thigh, popliteal fossa, and calf area were managed with the assistance of endoscopic surgery in 136 patients. Patients were divided into four types according to the normal veins involved in varicosities. With good illumination and magnified monitor viewing by means of a surgical endoscope, the main channel, tributaries of varicosities, incompetent perforating veins, and healthy veins could be clearly visualized and identified. Even though these varicosities had aberrant and tortuous courses, they could be completely dissected, divided, and then removed through one or more access incisions (2.5-3.0 cm in length). The incompetent perforating veins were also dissected and divided. The mean number of access incisions for each lower extremity was 2.2, 1.9, 1.3, and 1.0 for types I, II, III, and IV respectively. In all cases, the mean number of incisions was 1.6 in each lower limb. The most frequent morbidity was maceration of the access incision. Three wounds in 3 patients required debridement and resuturing, but the other wounds healed satisfactorily. Transient discoloration caused by bruising and numbness may present at the dissected area. There was no hematoma formation. Ischemic change with bleb formation of the dissected skin occurred in 1 patient. Subsequent secondary healing resulted in slight scarring in this area. With the assistance of endoscopic surgery, all the varicosities and the incompetent perforating veins could be completely dissected and removed. Accomplishment of removal of varicosities was double-checked between the preoperative skin marks of varicosities and the endoscopic findings. There is very little possibility for recurrence, because there were no residual varicosities or incompetent perforating veins after this operation. There was no recurrence in follow-up at least 2 months postoperatively. Patients were satisfied with the minimal surgical scarring and the complete absence of disfiguring varicosities.

Endoscopic excision of benign tumors in the forehead and brow

Twenty-five cases of benign tumor of the forehead and brow were excised successfully with endoscope-assisted surgery. The access incision was selected strategically behind the front hairline. For tumors in the middle of the forehead, the tumor was approached by subgaleal dissection. For those in the brow or temporal area, the dissection plane was just superficial to the deep temporal fascia. Patient age ranged from 3 to 59 years. The mass varied in size from 1.0 x 0.5 to 2.0 x 2.0 cm. There were 18 lipomas, 6 dermoid cysts, and 1 pilomatricoma. There was no residual mass or recurrence 1 to 24 months postoperatively. There was no paresthesia or numbness in the scalp. Patients and their families were greatly satisfied with this operation and the absence of visible scarring.