Evaluation of 242 consecutive parotidectomies performed for benign and malignant disease

Surgical Management of Patients with Parotid Involvement from Non-Melanoma Skin Cancer of the Head and Neck

We conducted a retrospective, longitudinal study on a single-center series of patients who underwent parotidectomy in the management of advanced head and neck non-melanoma skin cancer (hnNMSC). The aim of this study was to identify prognostic factors associated with worse outcomes. Forty-one men and nine women were included. The mean age at the time of surgery was 78.9 years. The 5-year overall survival, disease-specific survival, locoregional recurrence-free survival, and distant metastasis-free survival calculated with Kaplan-Meier curves were 39.9%, 56.3%, 58.6%, and 82.1%, respectively. A univariate analysis showed that the status of the margins, facial nerve direct involvement, lymph vascular invasion, and histological grading were associated with worse outcomes (p < 0.05). Positive margins were associated with worse disease-specific survival also in a multivariate analysis (p = 0.001, HR = 32.02, and CIs 4.338 to 351.3). Because the resection in free margins is the most important prognostic factor, early diagnosis or, in the case of advanced disease, extensive surgical resection with concomitant reconstruction is needed. Adjuvant therapy is indicated in selected cases.

Adamantinoma-like Ewing sarcoma of the salivary glands: a case report and systematic literature review

Adamantinoma-like Ewing sarcoma (ALES) of the salivary glands is an exceedingly rare malignancy defined by the t(11,22) EWSR1::FLI1 fusion, with complex epithelial differentiation. To identify features that can allow for better recognition of this disease entity, we reviewed all published reports of molecularly confirmed ALES of the salivary glands and explored epidemiological, clinical, radiological, pathological, and therapeutic characteristics of a population of 21 patients including a single newly reported patient from our group. We searched the English-language literature indexed in PubMed, Medline, Scopus, and Web of Science using the keyword 'Adamantinoma-like Ewing sarcoma' published up to June 2022. The median age at diagnosis was 46 years, and a slight female sex predilection was observed. Most tumors originated in the parotid gland (86%) and presented as a painless palpable mass with a median diameter of 3.6 cm. Metastatic dissemination was reported only in one patient (5%), and after a median follow-up of 13 months the 1-year overall survival rate was 92%. Salivary gland ALES were frequently misdiagnosed at presentation (62% of cases) and were pathologically characterized by the presence of highly monomorphic small round blue cells with infiltrative pattern and positive immunostaining for CD99 and high- and low-molecular weight cytokeratins. Epidemiological and clinical features of salivary gland ALES raise questions on the incorporation of this malignancy in the Ewing sarcoma family tumor group.

Salivary gland tumours: an epidemiological review of non-neoplastic and neoplastic pathology

Salivary gland tumours (SGT) demonstrate geographical variation. The primary objective of this study was to determine the types, frequency, distribution, and demographics of non-neoplastic and neoplastic salivary gland pathology at Waikato Hospital, New Zealand (NZ) over a 10-year period. Following this we conducted a 10-year retrospective review of SGT epidemiology from international literature. In total 825 patients were identified, 31% (256/825) with non-neoplastic salivary gland pathology, 34% (284/825) with benign neoplastic pathology, 14% (118/825) with primary malignant lesions, 18% (146/825) with metastatic SGTs, and 3% (21/825) with lymphoma. Patients had a mean (range) age of 58 (3-102) years, were predominantly male (58%, 476/825), and NZ European (65%, 536/825). Tumours were most prevalent in the parotid gland (85%, 484/569), of which 44% (211/484) were malignant. Pleomorphic adenoma was the most common benign (71%, 203/284) and overall (36%, 203/569) tumour, while mucoepidermoid carcinoma (25%, 29/118) and squamous cell carcinoma (SCC) (73%, 106/146) were the most common primary malignant and metastatic SGTs, respectively. Our literature review identified 18 studies consisting of 33,933 patients, of whom 71% (24,013/33,933) had benign SGTs. Pleomorphic adenoma (68%, 16404/24013) and mucoepidermoid carcinoma (29%, 2826/9621) were the most common benign and malignant SGTs, respectively. Low numbers of non-neoplastic and metastatic SGTs were reported in the literature. This research provides a greater understanding of differences in their global distribution. Consistent with previous literature, pleomorphic adenoma and mucoepidermoid carcinoma were the most common benign and malignant SGTs. In NZ, we found high rates of malignant SCC to the parotid gland, consistent with the epidemiology of non-melanoma skin cancer in the country.

Lipofilling after total parotidectomy: a useful option to prevent functional and aesthetic sequelae

Objective

Parotidectomy is the main treatment for parotid tumours, but its functional and aesthetic sequelae can be very disturbing for patients.

Methods

15 patients underwent total conservative parotidectomy, harvesting of a superficial musculoaponeurotic system (SMAS) flap and lipofilling between May 2014 and June 2020 for a benign parotid tumour. Aesthetic, functional sequelae and cosmetic results were assessed with the House-Brackmann scale, Luna-Ortiz's classification and a semiquantitative questionnaire. Lipofilling resorption was analysed by maxillofacial and neck MRI imaging at 2 years after surgery. The results were compared to a group of 21 patients who underwent total parotidectomy without harvesting a SMAS flap and lipofilling.

Results

No complications were observed. No facial defects were seen during follow-up. Post-operative MRI showed fat resorption was less than 20% in 12 patients and from 20 to 30% in 3 patients. Cosmetic satisfaction was 100% in all cases. Only 1 patient (6%) complained of Frey's syndrome.

Conclusions

Lipofilling is an excellent solution considering its efficacy, safety, simplicity, duration over time and economic costs. Donor site invasiveness is minimal, and reintervention is always possible. Face-lift incision and SMAS flap can improve aesthetic results and minimise the disfiguring impact of the surgical scar.

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.

Metastatic Cutaneous Squamous Cell Carcinoma Involving the Parotid Gland: Experience Outside of the Sun Belt

OBJECTIVE

To characterize a subset of patients with metastatic head and neck cutaneous squamous cell carcinoma in a tertiary North American center and describe oncologic outcomes following definitive treatment.

STUDY DESIGN

Retrospective chart review.

SETTING

National Cancer Institute-designated Comprehensive Cancer Center.

METHODS

We conducted a retrospective chart review of patients with cutaneous squamous cell carcinoma with metastases to intraparotid lymph nodes who underwent parotidectomy between 1993 and 2020. Baseline patient and tumor characteristics were assessed. Regional control, disease-specific survival, and overall survival were estimated using Kaplan-Meier method. Multivariate analysis was used to determine the relationship between adverse pathological features and survival.

RESULTS

A total of 122 patients were included. The median age was 76, 84.4% of patients were male, and 17.2% were immunosuppressed. Regional control, disease-specific survival, and overall survival were 68.5%, 70.7%, and 59.4% at 5 years, respectively. Perineural and lymphovascular invasion were predictive of worse disease-specific survival. Extracapsular spread was observed in 90.2% of patients and was not a significant predictor of outcome.

CONCLUSIONS

We found the demographics and oncologic outcomes of our cohort in the Northeast United States to be comparable with those previously reported in Australia and the Sun Belt of the United States. We noted a high rate of extracapsular spread but did not find it to be a significant predictor of recurrence or survival. Future efforts should address the impact of extracapsular spread on prognosis and adjuvant treatment decisions.

Histopathological evaluation of parotid gland neoplasms in Queensland, Australia

BACKGROUND

Parotid gland tumours are complex neoplasms with a broad histological range. The parotid gland is also a common site of face and scalp skin cancer metastases.

METHOD

Parotidectomies performed by ENT department in the Gold Coast health district from 2006 to 2013.

RESULTS

A total of 158 specimens were examined. Of these, 53.80 per cent were benign and 46.20 per cent were malignant. Pleomorphic adenoma was the most common tumour (29.11 per cent), followed by cutaneous squamous cell carcinoma (23.42 per cent) and Warthin's tumour (12.03 per cent).

CONCLUSION

Metastatic squamous cell carcinoma accounted for a large proportion of parotid masses in our case series, reflecting the high prevalence of non-melanoma skin cancer in Australia. Primary parotid neoplasms had similar incidence rates to other studies.

Galvanic skin response test: a new quantitative diagnostic method for Frey syndrome

OBJECTIVE

Frey syndrome is one of the most common complications following parotid surgery. The current most common test for objectively diagnosing Frey syndrome is Minor starch-iodine test. This test might be insufficient because its results are not quantitative and therefore tests with quantitative results are investigated. The objective of this study was to investigate the efficiency of galvanic skin response (GSR) test, which measures changes in skin resistance, as a method with quantitative results for diagnosis of Frey syndrome.

METHODS

Thirty patients who underwent superficial parotidectomy were assessed postoperatively (mean, 24.7 ± 25.7 months; range, 6-109 months). Patients completed a symptomatic evaluation questionnaire and underwent Minor starch-iodine test and GSR.

RESULTS

Diagnostic validity of GSR test was found to be >2.91 following analysis. Sensitivity and specificity of this value were 100% and 55%, respectively, based on symptomatic assessment. Sensitivity and specificity were 87.5% and 57.1%, respectively, based on Minor starch-iodine test.

CONCLUSIONS

When compared to symptomatic evaluation of patients who underwent superficial parotidectomy, GSR test was shown to be 100% sensitive in diagnosing Frey syndrome and quantitative results of GSR test could determine severity of Frey syndrome.

Facial disability index (FDI): adaptation to Spanish, reliability and validity

Objectives: To adapt to Spanish the facial disability index (FDI) described by VanSwearingen and Brach in 1995 and to assess its reliability and validity in patients with facial nerve paresis after parotidectomy. Study Design: The present study was conducted in two different stages: a) cross-cultural adaptation of the questionnaire and b) cross-sectional study of a control group of 79 Spanish-speaking patients who suffered facial paresis after superficial parotidectomy with facial nerve preservation. The cross-cultural adaptation process comprised the following stages: (I) initial translation, (II) synthesis of the translated document, (III) retro-translation, (IV) review by a board of experts, (V) pilot study of the pre-final draft and (VI) analysis of the pilot study and final draft. Results: The reliability and internal consistency of every one of the rating scales included in the FDI (Cronbach’s alpha coefficient) was 0.83 for the complete scale and 0.77 and 0.82 for the physical and the social well-being subscales. The analysis of the factorial validity of the main components of the adapted FDI yielded similar results to the original questionnaire. Bivariate correlations between FDI and House-Brackmann scale were positive. The variance percentage was calculated for all FDI components. Conclusions: The FDI questionnaire is a specific instrument for assessing facial neuromuscular dysfunction which becomes a useful tool in order to determine quality of life in patients with facial nerve paralysis. Spanish adapted FDI is equivalent to the original questionnaire and shows similar reliability and validity. The proven reproducibi-lity, reliability and validity of this questionnaire make it a useful additional tool for evaluating the impact of facial nerve paralysis in Spanish-speaking patients.

Key words:Parotidectomy, facial nerve paralysis, facial disability.

Pleomorphic adenoma of the parotid: formal parotidectomy or limited surgery?

BACKGROUND

Optimal surgery for pleomorphic adenoma of the parotid is controversial. In the present review, we discuss the advantages and disadvantages of the various approaches after addressing the surgical pathology of the parotid pleomorphic adenoma capsule and its influence on surgery.

DATA SOURCES

PubMed literature searches were performed to identify original studies.

CONCLUSIONS

Almost all pleomorphic adenomas can be effectively treated by formal parotidectomy, but the procedure is not mandatory. Extracapsular dissection is a minimal margin surgery; therefore, in the hands of a novice or occasional parotid surgeon, it may result in higher rates of recurrence. Partial superficial parotidectomy may be a good compromise. The tumor is removed with a greater cuff of healthy parotid tissue than in extracapsular dissection. This may minimize the recurrence rate. On the other hand, the removal of healthy parotid tissue compared with formal parotidectomy is limited, thus minimizing complications such as facial nerve dysfunction and Frey syndrome.

[Histomorphologic findings in the facial nerve after water-jet dissection of the parotid gland in dogs]

BACKGROUND

Initial results on the application of the water-jet in a parotidectomy setting in an animal study demonstrate that there are morphologic changes which do, and some which do not, affect the clinial function of the facial nerve due to the different jet sizes and operating pressures used. In a further study the histomorphometric data of the facial nerve dissected by the water-jet should be evaluated and correlated to the different sizes of jet and operating pressures.

MATERIAL AND METHODS

In total, 102 nerves (in 14 beagles) which had been dissected by water-jets of different sizes and operating pressures were evaluated. After an observation period of 21 days, including documentation of the clinical function of the facial nerve, the nerves were dissected. The number of nerve fibers and the diameter of the different nerve fibers were then evaluated.

RESULTS

All nerve fibers dissected with jet sizes of 120 and 150 μm showed an identical cumulative frequency of fiber diameters. All nerve fibers dissected with a water-jet of 200 μm showed morphologic and clinical abnormalities and--in terms of nerve fiber diameters--clear differences to the nerve fibers dissected with 120- or 150-μm jets. Altogether, there is a decrease in fiber diameter along the nerve course.

CONCLUSION

Our data show a shift of larger diameters of the nerve trunk to smaller diameters in the terminal nerve fibers. This phenomenon has not been described in the literature to date and is probably not due to the water-jet. Additionally, our data show that 22% of the original nerve fiber damaged by the water-jet is sufficient to preserve the nerve's clinical function.

Parotid carcinoma: Current diagnostic workup and treatment

In this review we present recent progress in diagnostic workup, prognostic evaluation, treatment options and resulting outcomes. Whenever possible, complete resection remains the mainstay of treatment. Sacrifice of facial nerve branches is reserved for the clinically or electromyographically dysfunctioning facial nerve. Clinical or radiological neck disease demands combined surgery and radiotherapy. Treatment of the N0 neck is indicated for advanced stage-high grade tumors but the question remains unanswered whether this should be surgical or radiotherapeutic elective treatment. Surgery alone will cure low stage, low grade tumors, that show no additional negative prognostic factors following adequate resection. In all other tumors postoperative radiotherapy will improve locoregional control. This approach results in good locoregional control, in a way that distant metastasis remains the typical presentation of treatment failure. In this setting, the results of systemic treatment today remain limited, but a huge effort in the molecular biology field has been done to introduce targeted therapy into this domain of head and neck cancer. Disease control remains variable within the patient population. This variation can increasingly be predicted by systems that incorporate the combined information of multivariately identified and quantified prognostic factors into an individualized prognosis for the parotid carcinoma patient.

Analysis of complications following surgical treatment of benign parotid disease

BACKGROUND

The objective of the study was to study the incidence of, and risk factors for developing complications following parotidectomy for benign disease, to improve preoperative patient counselling and better inform future surgical management.

METHODS

An 11-year retrospective review of 162 parotidectomies for benign disease, collecting and analysing data about presentation, investigations, surgical treatment, postoperative facial nerve function, Frey's syndrome and other surgical complications.

RESULTS

The mean age at presentation was 58 years. The commonest pathology was benign pleomorphic adenoma (43%), followed by Warthin's tumour (30%) and chronic sialadenitis (22%). Sialadenitis was a significant risk factor for facial nerve palsy and increased the incidence of salivary fistulas. Parotid duct ligation increased the risk of nerve palsy in the distribution of zygomatic and buccal branches. Operations for Warthin's tumour were associated with an increased risk of dysfunction of the cervical branch of the nerve. Half the patients had intraoperative facial nerve stimulation and this did not influence the likelihood of facial paresis. The recovery of facial nerve function showed a biphasic distribution, with 90% of patients having normal function within 12 months, followed by a slower recovery rate for up to 2 years.

CONCLUSION

The incidence of postoperative complications was influenced by the pathology, with inflammatory lesions significantly increasing the risk of facial nerve dysfunction and other complications, but also by variations in surgical practice, such as parotid duct ligation. Overall, the incidence of permanent facial paralysis was less than 2%, but temporary nerve palsy was common at 40%, with most patients regaining normal function within 1 year of the operation.

[Partial parotidectomy--alternative method in surgical management of parotid gland Warthin tumours]

82 patients with adenolymphoma of parotid gland treated with surgery in Department of Oncological Surgery Cancer Center, Gliwice in the period of 1986-2004 were retrospectively analyzed. They were about 22% of all patients with parotid gland tumors operated in that period. In almost 70% of cases partial parotidectomy with facial nerve preservation was performed as a treatment of choice. In that group DFS was over 95%. Local recurrence occurred in less then 5%, only in cases with multiple tumor in histopathological examinations. Quality of life parameters were also analyzed. In the analysis complications rate increased with the extension of surgical treatment. It revealed in the postoperative cosmetic defect evaluation. Partial resection of the parotid gland could be useful method of surgical treatment of adenolymphoma selected cases. It allows to achieve the same results as classic parotidectomy with lower risk of significant complications. In analyzed group the local recurrence was always combined with multi lesional growth of the tumor.

Clinical Outcome After Surgery for 75 Patients With Parotid Sialadenitis

OBJECTIVE

To analyze the clinical outcome of patients treated surgically for chronic parotid sialadenitis.

STUDY DESIGN

A retrospective cohort study of patients whose clinicopathologic information had been collected prospectively onto a dedicated head and neck database.

METHODS

Between 1987 and 2006, a total of 75 patients had 78 parotidectomies, 17 superficial and 61 near-total, to treat chronic parotid sialadenitis. The clinicopathologic data including treatment morbidity and outcome were analyzed.

RESULTS

Temporary postoperative facial weakness occurred in 26 (33%) patients, and this was permanent, although partial, in one (1%) patient. There was no significant difference (P > .05) in the incidence of temporary facial nerve neuropraxia in the superficial (35%) and near-total parotidectomy (33%) groups. Recurrence of symptoms was noted in two patients who had undergone near-total parotidectomy and none of the patients who had undergone superficial parotidectomy. Chronic parotid sialadenitis was effectively treated in 97% of patients undergoing parotidectomy.

CONCLUSION

Near-total parotidectomy is a safe and efficacious surgical treatment in the management of patients with debilitating severe chronic parotid sialadenitis.

Squamous cell carcinoma of the parotid gland

BACKGROUND

Our objective was to evaluate the outcome of patients treated for squamous cell carcinoma (SCC) of the parotid gland.

METHODS

We conducted a retrospective chart review of the tumor registry from 1982 through 2003 at a tertiary referral medical center. Patients with SCC of the parotid gland were identified and followed for a minimum of 2 years after therapy.

RESULTS

SCC involving the parotid was identified in 66 patients. The tumor was a metastasis from a known primary site in 41 patients (62%). In 16 patients (24%), no other primary site was identified, and the tumor may have originated in the parotid gland. Nine patients (14%) were undetermined. Therapy frequently included surgery. The integrity of the facial nerve was preserved in 92% of surgical patients. Only eight patients initially had clinical evidence of cervical metastasis; however, cervical metastasis was identified in 25 patients (44%), changing the course of therapy.

CONCLUSION

SCC of the parotid gland was metastatic from a known primary tumor in more than half of the patients. The most common site of the primary tumor was a cutaneous malignancy of the head and neck. The high incidence of cervical lymph node involvement underscores the diagnostic and therapeutic importance of neck dissection with parotidectomy.

Risk of facial palsy and severe Frey's syndrome after conservative parotidectomy for benign disease: analysis of 610 operations

CONCLUSIONS

Advanced age, long operation time and large specimen volume were significant risk factors for transient facial palsy after conservative parotidectomy. Revision operation was the only risk factor for development of a permanent palsy. Risk factors for Frey's syndrome were not found. The incidence of Frey's syndrome was not altered by the use of a sternocleidomastoid muscle flap or other implantation material.

OBJECTIVES

The results of studies identifying risk factors for facial palsy and Frey's syndrome after parotidectomy are contradictory. This study attempted to identify these risk factors by performing a retrospective review of a large series of patients.

PATIENTS AND METHODS

A total of 610 standardized conservative parotidectomies for benign diseases performed between 1989 and 2004 were studied retrospectively. The risk factors for facial palsy and Frey's syndrome were determined by univariate and if possible by multivariate analysis of variables related to patient demographics and operation characteristics.

RESULTS

The rates of transient facial palsies, permanent facial palsies and Frey's syndrome were 18%, 4%, and 4%, respectively. Significant univariate and multivariate risk factors for development of a transient facial palsy were age>70 years, operation time>260 min, and a specimen volume>70 cm3. The only significant risk factor for the development of a permanent palsy was prior surgery. A significant risk factor for the development of Frey's syndrome could not be estimated.

Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations

OBJECTIVE/HYPOTHESIS

The objective of this study was to analyze the perioperative and long-term complications after standardized lateral and total parotidectomy for benign parotid tumors and chronic parotitis with special regard on the training skill of the surgeons at a university teaching center. All teaching operations were performed under strict microscopic control and supervision of experienced surgeons.

STUDY DESIGN

The authors conducted a retrospective unicentric study in a tertiary university center.

METHODS

Medical records of 963 lateral and total parotidectomies treated from 1986 to 2004 were analyzed with regard to perioperative and long-term complications. The surgeons' expertise to perform a parotidectomy was classified as beginner (0-20 parotidectomies performed), advanced (21-50), experienced (51-100), or highly experienced (>100).

RESULTS

Eighty-five percent of the cases were primary operations (85%) and 15% revision operations. A lateral parotidectomy was necessary in 61% and total parotidectomy in 39%. The mean operation time was 192 minutes. The incidence of transient facial nerve dysfunction was 25%, and 6% for permanent weakness, respectively. Treatment for Frey's syndrome was performed in 5%. First recurrence for pleomorphic adenoma was observed in 2% and for Warthin's tumor in 3%. Significantly more complications were seen after total parotidectomy and in revision cases. Beginners and advanced surgeons (operated 41% of the cases) needed a longer operation time than experienced and highly experienced surgeon (59% of the cases). The surgeon's expertise had no influence on the incidence of complications.

CONCLUSIONS

Standardized education in lateral and total parotidectomy for treatment of benign parotid disease under precise microscopic control is safe, demonstrates good results, and has low perioperative and long-term morbidity.

Endoscopie des canaux salivaires : toujours plus petit, toujours plus loin ?

Sialendoscopy is a new minimally invasive technique allowing exploration of the submandibular and parotid ducts with treatment for sialolithiasis and stenosis. Used for diagnostic purposes, sialendoscopy may be an alternative to classical radiological methods. As an interventional technique, it allows a significant reduction in the number of indications for submandibular and parotid resections.

Facial nerve dysfunction after parotidectomy: the role of local factors

OBJECTIVES/HYPOTHESIS

The objective was to analyze the incidence and factors associated with facial nerve dysfunction after conservative parotidectomy with facial nerve dissection.

STUDY DESIGN

A retrospective unicentric study in a tertiary care center with prospective record of studied factors.

METHODS

Over a 10-year period, 131 patients with normal facial nerve function underwent a superficial or total conservative parotidectomy with nerve dissection performed by one surgeon for primary benign or malignant tumors. Facial nerve function was assessed on the first postoperative day and at 1 month and 6 months after the parotidectomy. Extent of surgery, histopathological findings, tumor size, close contact of tumor with facial nerve, and sex and age of the patient were reviewed. These variables were studied in a chi2 statistical univariate and stratified analysis to determine their association with postoperative facial nerve dysfunction.

RESULTS

Incidence of postoperative facial nerve dysfunction was 42.7% on the first postoperative day, 30.7% at 1 month after the parotidectomy, and 0% at 6 months after the parotidectomy. The most common dysfunction was paresis in a single nerve branch (48.2%), in particular, the marginal mandibular branch. Total parotidectomy was associated with a significantly higher incidence of facial nerve dysfunction during the first postoperative period (60.5% at day 1 and 44.7% at month 1) than superficial parotidectomy (18.2% at day 1 and 10.9% at month 1) (P < .001). In patients with total parotidectomy, close contact of the tumor with the facial nerve was found to have statistical causal relation with facial nerve weakness. In patients with superficial parotidectomy, inflammatory conditions were found as factors that increased postoperative facial nerve dysfunction.

CONCLUSION

In the study series of conservative parotidectomies with facial nerve dissection, only extent of surgery and particular local conditions of nerve dissection, especially the close contact of tumor with facial nerve and inflammatory conditions, were found to be associated with postoperative facial nerve dysfunction.

Management of primary malignant epithelial parotid tumors

Parotid cancers are infrequently encountered. These tumors carry a prolonged risk of recurrence and metastasis. Controversies surrounding pre-treatment evaluation by imaging and fine needle aspiration, utility of operative frozen section are partly resolved. Though surgery remains the mainstay of treatment, radiation is being recognized as a useful adjuvant. Facial nerve preservation is one of the important goals at surgery. The role of chemotherapy is still investigational. The prognosis and necessity of elective neck treatment are mainly guided by the tumor grade and stage.

Primary parotid malignoma surgery in patients with normal preoperative facial nerve function: outcome and long-term postoperative facial nerve function

OBJECTIVES/HYPOTHESIS

Most patients with primary parotid cancer present with normal facial nerve function. The common surgical strategy for these patients is to perform a parotidectomy with facial nerve preservation. Nevertheless, the functional outcome for the facial nerve and oncological outcome is unclear.

STUDY DESIGN

Medical records of 211 patients treated from 1986 to 2000 in an university hospital were reviewed. One hundred seven patients with primary surgery for primary parotid cancer and long-term follow-up were analyzed retrospectively.

METHODS

The characteristics, treatment, and oncological outcome were evaluated using hospital chart data. All patients with postoperative facial paresis were had follow-up with electromyography until recovery or permanent paresis became apparent.

RESULTS

Ninety-one patients had a normal preoperative function. Facial nerve preservation during surgery by total parotidectomy was possible in 79 patients, whereas in 28 patients a radical parotidectomy was necessary. Otherwise, the oncological characteristics of both groups were not different. Directly after total parotidectomy, half of the patients presented a facial paresis but only two patients (2%) developed a permanent partial paresis. The 5-year disease-free rate and the 5- and 10-year survival rates were 65%, 83%, and 54%, respectively. After radical parotidectomy, the results were not significantly different. The 5-year disease-free rate and the overall 5- and the 10-year survival rates were 56%, 62%, and 42%, respectively.

CONCLUSION

Treatment of primary parotid cancer with preoperatively normal facial nerve function by standardized parotidectomy and precise microsurgical preservation of the facial nerve is often possible. This approach demonstrates favorable oncological results with a low level of long-term facial nerve morbidity.

Current management of benign parotid tumors--the role of limited superficial parotidectomy

BACKGROUND

Parotid tumors are mostly benign, but their evaluation and treatment require a thorough knowledge of the relevant anatomy and pathology. Surgical treatment of benign tumors is aimed at complete removal of the mass with facial nerve preservation. The aim of this study was to evaluate the results of treatment of benign parotid neoplasms when surgery entailed limited superficial parotidectomy.

METHODS

All patients with benign parotid tumors treated by the author from 1988 to 2002 were reviewed. Data had been prospectively accessioned onto the computerized database of the Department of Head and Neck Surgery, RPAH. Limited superficial parotidectomy was carried out in all previously untreated patients with tumors superficial to the plane of the facial nerve. Median follow-up time was 6 years (range, 1-14 years).

RESULTS

A total of 363 parotidectomies was carried out on 355 patients, 29 of whom (8%) were previously treated. Tumors arose deep to the plane of the facial nerve in 40 patients (11%), and, of these, 16 occupied the parapharyngeal space. Pleomorphic adenoma (70%) and Warthin's tumors (15%) were the most common pathologic types. Temporary postoperative facial weakness occurred after 98 operations (27%). Facial weakness was permanent in 2.5% of patients (9 cases) who had normal preoperative function; however, in this group the facial nerve was intentionally resected in 2 patients, 3 others had had previous surgery, and 1 had a deep lobe tumor. Tumor recurrence developed in three patients (0.8%), two of whom had been previously treated.

CONCLUSION

Complete superficial parotidectomy is unnecessary in the treatment of benign localized parotid tumors. Limited parotidectomy is associated with very low rates of morbidity and recurrence. Preoperative investigations should be used selectively; however, the author recommends routine (or at least liberal) use of fine-needle aspiration biopsy.

The impact of malignant disease on facial nerve function after parotidectomy

OBJECTIVES/HYPOTHESIS

Studies of immediate postoperative facial nerve function following parotidectomy focus on benign disease. The purpose of the study was to compare facial nerve function with regard to benign or malignant disease in patients undergoing superficial parotidectomy.

STUDY DESIGN

Retrospective cohort study of consecutive patients undergoing parotidectomy between 1995 to 2002.

METHODS

House-Brackmann (HB) grade was recorded or assigned at the first postoperative visit. For patients with HB grade of III or greater, final resolution of facial nerve function was recorded. A chi2 analysis for independence was conducted between patients with HB grade of II or less and those with HB grade of III or greater and final pathological finding (benign vs. malignant disease). Mean and median times to resolution were determined for patients with HB grade of III or greater. Times to resolution for benign and malignant disease for those with HB grade of III or greater were compared (Kaplan-Meier method).

RESULTS

Sixty-seven patients with benign disease and 52 with malignant disease were included. Ninety-four percent of patients with benign disease had HB grade of II or less at first postoperative visit (mean period, 11.6 d) compared with 76.9% of patients with malignant disease (mean period, 12.4 d). A chi2 analysis found this difference significant (chi2 = 7.36, P =.0067). Time to resolution for HB grade of III or greater was 253.8 days (+/-168.2 d) with median time of 229.5 days for benign disease and 182.4 days (+/-134.6 d) with median time of 138 days for malignant disease. Kaplan-Meier comparison found no significant differences in time to final resolution (P =.83). Three patients in the group with malignant disease had unresolved dysfunction (one patient for >2 y).

CONCLUSIONS

Patients with benign disease have a greater chance of having HB grade of II or less immediately following surgery; however, whether the disease is benign or malignant, long-term final facial nerve function is the same.

Treatment results of regional metastasis from cutaneous head and neck squamous cell carcinoma

AIMS

To investigate the results of our treatment policy, we present our institutional experience in the management of regional neck node metastases of cutaneous head and neck squamous cell carcinoma (CHNSCC).

METHODS

Between 1977 and 1997, 343 patients presented with CHNSCC, of whom 41 were treated for regional metastases, with parotidectomy and/or (selective) neck dissection. Histological analysis was performed on all operation specimens. Patients with multiple nodes and/or extra capsular rupture, at risk for recurrence, received adjuvant radiotherapy.

RESULTS

Seventy-six percent of the regional metastases occurred within the first 2 years, but a delay of more than 5 years was also observed. Parotid gland (56%), neck levels II (39%) and V (22%) were most frequently involved. Twenty-four percent of patients treated with curative intent failed at the regional site. Five years overall survival was 46%, with a median survival of 49 months. No survival differences emerged between patients treated by surgery alone and patients receiving adjuvant radiotherapy (P=0.14). Five patients died of disease, of whom three with distant metastases.

CONCLUSION

Regionally metastasized CHNSCC is a serious disease with a high risk of regional recurrence, calling for combined surgery and adjuvant radiotherapy. A small subset of patients with a long interval between completion of primary treatment and presence of regional nodes justifies a long follow-up.

Clinical and radiological evidence to support superficial parotidectomy as the treatment of choice for chronic parotid sialadenitis: a retrospective study

We present a retrospective series of 23 consecutive parotidectomies, over a 10-year period (1989-1999) for 22 patients with chronic sialadenitis unresponsive to conservative measures. There were 10 male and 12 female patients. Mean age was 52 years (range 12-72), and mean duration of symptoms 4.5 years (range 8 months-30 years). All patients had preoperative sialography and 2 had computed tomography to exclude a neoplasm. A complete superficial parotidectomy with preservation of the main duct was done in all cases. Fifteen patients developed temporary facial nerve weakness postoperatively and 7 developed Frey's syndrome. There were no cases of permanent facial nerve palsy. Nineteen patients reported complete resolution of their symptoms and 3 patients had mild persisting symptoms that did not necessitate any further treatment. Histologically there was evidence of sialadenosis in one case and benign lymphoepithelial lesion in another; the others showed evidence of chronic sialadenitis of varying degrees of severity. Fifteen patients had postoperative sialograms, of which 11 showed evidence of some filling of residual parotid gland parenchyma and in 8 patients there was filling of a normal-looking accessory lobe. In this series, superficial parotidectomy with preservation of the main duct was safe and effective, with minimal long-term complications, for most patients with chronic parotid sialadenitis that was unresponsive to conservative measures and, in some patients, it allowed some preservation of function. The potential damage to the facial nerve and the cosmetic problems associated with a total or near-total parotidectomy were avoided.

Water-jet dissection in parotid surgery: an experimental study in dogs

OBJECTIVE

The objective of the present study was to investigate the application of the water-jet dissection method in parotid surgery by way of animal experiments, paying particular attention to the clinical and histological reactions of the facial nerve.

STUDY DESIGN

An animal experimental study.

METHODS

Total bilateral parotidectomies with retention of the facial nerve were performed on 19 beagle dogs by means of the Hydro-Jet device (Andreas Pein Medizintechnik Company, Schwerin, Germany) using different jet diameters and operating pressures. All operations were performed with continuous intraoperative facial monitoring (Neurosign 100, Inomed Company, Teningen, Germany). The dogs were monitored postoperatively over an average period of 20.3 days (range, 14-35 d). Local findings and facial nerve status were documented daily. In a second phase, the dissected nerves were resected and the animals were killed. Samples of water-jet-dissected parotid tissue, as well as all dissected nerve branches, underwent histological examination and were compared with clinical and electrophysiological findings.

RESULTS

It was possible to perform operations easily on all parotid glands by means of the Hydro-Jet using the small, 120-microm jet at operating pressures of 40 to 60 bar and to dissect the facial nerve quickly and safely with retention of its functional capability (n = 34). The dissection of nerves using larger-diameter jets (150 and 200 microm [n = 64]) resulted in a total of two reversible and seven irreversible partial pareses.

CONCLUSIONS

The study has shown that it is possible to perform tissue-selective operations on the parotid gland by means of the Hydro-Jet using the 120-microm jet at operating pressures of 40 to 60 bar, ensuring safe, atraumatic dissection of the facial nerve with retention of its functional capability. The advantages of the new Hydro-Jet method offer a valuable alternative compared with the normal dissection methods adopted in parotid surgery. Thus the results of the present investigation currently are being checked within the framework of a clinical study at our clinic.

Combined sentinel lymphadenectomy and mohs micrographic surgery for high-risk cutaneous squamous cell carcinoma

BACKGROUND

There are subgroups of cutaneous squamous cell carcinoma (SCC) that have a higher risk for both regional and distant metastasis. When cutaneous SCC does metastasize, it typically spreads first to local nodal groups. Sentinel lymph node (SLN) localization has been successfully used to evaluate nodal metastasis in breast carcinoma, melanoma, and other select tumors. It may also be useful in certain high-risk cutaneous SCCs. Currently, Mohs micrographic surgery is the treatment of choice for these tumors.

METHODS

A patient presented with a high-risk recurrent SCC on the forehead. The regional nodal groups were clinically negative and radiographically negative by computed tomographic scan. Sentinel lymphadenectomy was performed by means of technetium 99m-radiolabeled sulfur colloid. The main tumor was resected with Mohs micrographic surgery.

RESULTS

A left preauricular SLN was localized by lymphoscintigraphy. The SLN was located intraoperatively by means of a gamma probe and excised. Subsequent pathologic evaluation of the SLN was negative for evidence of metastatic SCC by light microscopy with hematoxylin and eosin, and with immunohistochemical stains for cytokeratins AE1 and AE3. The day after SLN excision, the tumor was removed via Mohs micrographic surgery with clear surgical margins after a total of 8 stages. Aggressive subclinical spread by both subcutaneous "skating" and perineural invasion was noted.

CONCLUSION

The combination of Mohs micrographic surgery and sentinel lymphadenectomy is feasible and has theoretical utility in the management of a subset of cutaneous SCCs at high risk for metastasis. The ability of sentinel lymphadenectomy to identify regionally metastatic cutaneous SCC as well as the additive benefit of SLN and Mohs micrographic extirpation in the treatment of high-risk cutaneous SCC remain to be further clarified.

Postparotidectomy facial nerve paralysis: possible etiologic factors and results with routine facial nerve monitoring

OBJECTIVE

Analyze the incidence and factors responsible for postparotidectomy facial nerve paralysis when the surgery is performed with the routine use of facial nerve monitoring.

STUDY DESIGN

A prospective, nonrandomized study.

METHODS

Seventy consecutive patients underwent parotidectomy with intraoperative facial nerve monitoring. Two devices were used: a custom mechanical transducer and a commercial electromyograph-based apparatus. All patients were analyzed, including those with cancer and those with deliberate or accidental sectioning of facial nerve branches. The outcome variables were the motor facial nerve function according to the House-Brackmann grading scale (HB) at 1 week (temporary paralysis) and 6 to 12 months (definitive paralysis). Facial nerve grading was performed blindly from reviewing videotapes.

RESULTS

The overall incidence of facial paralysis (HB>1) was 27% for temporary and 4% for permanent deficits. Most of the deficits were partial, most often concerning the marginal mandibular branch. Temporary deficits with HB scores of greater than 2 were only present in patients with parotid cancer or infection. Permanent deficits were present in three patients, including one patient with facial nerve sacrifice. Factors significantly associated with an increased incidence of temporary facial paralysis include the extent of parotidectomy, the intraoperative sectioning of facial nerve branches, the histopathology and the size of the lesion, and the duration of the operation.

CONCLUSIONS

Despite a stringent accounting of postoperative facial nerve deficits, these data compare favorably to the literature with or without the use of monitoring. An overall incidence of 27% for temporary facial paralysis and 4% for permanent facial paralysis was found. Although the lack of a control group precludes definitive conclusions on the role of electromyograph-based facial nerve monitoring in routine parotidectomy, the authors found its use very helpful.

Metastatic tumours of the parotid gland

Twenty patients (12 men and 8 women, median age 69 years) with metastatic tumours in the parotid gland who presented over a 12-year period were evaluated retrospectively. Preoperative investigations included fine needle aspiration cytology (n = 11) and computed tomography or magnetic resonance imaging (MRI) (n = 14). Most tumours originated from the head and neck region, the two main types being squamous cell carcinoma (n = 10) and malignant melanoma (n = 7). All 20 presented with a parotid mass and 11/20 (55%) had associated lymphadenopathy. Eleven patients (55%) underwent superficial, five total, and four radical, parotidectomy. Neck dissection was required in 16 patients (80%), and all 11 patients with clinically palpable lymph nodes had evidence of tumour in the neck dissection specimens. Half of all patients (n = 10) received adjuvant postoperative radiotherapy. Three-quarters of the patients (n = 15) were alive after a mean follow-up of 31 months and only one developed a marginal recurrence. The cumulative 5-year survival rate was 51%, and there was no significant difference (P = 0.48) in the 3-year survival rates of patients who had radical compared with those who had modified neck dissections. Patients who had superficial parotidectomy had a longer overall survival compared with those who had total or radical parotidectomy (P = 0.04) perhaps reflecting the advanced nature of tumours that required total or radical excision of the gland. We conclude that superficial parotidectomy is usually an adequate treatment for secondary parotid tumours (when disease is clinically limited to the superficial lobe), and we suggest that patients in whom metastatic disease of the parotid gland is suspected do not require neck dissection if they have no palpable lymph nodes and MRI shows no evidence of spread. There seems to be no survival advantage in radical over modified neck dissection.

Parotid and submandibular sialadenitis treated by salivary gland excision

BACKGROUND

The purpose of the present study was to compare and contrast the clinicopathological features and treatment outcome of chronic sialadenitis involving the parotid and submandibular glands, among patients who were treated by excision of the affected gland.

METHODS

In a series of 88 patients treated over an 8-year period, 47 had parotid sialadenitis and 41 had submandibular sialadenitis. In the parotid group, 63% of patients were symptomatic for longer than 6 months compared with 27% in the submandibular group. Calculi were implicated in the disease process in 24% of patients with parotid sialadenitis, compared with 73% of patients with submandibular disease.

RESULTS

Patients with parotid sialadenitis had superficial (n = 14) or near-total parotidectomy (n = 35), while those with submandibular sialadenitis underwent total gland excision. Complications occurred twice as frequently in the parotidectomy group. The rate of temporary facial nerve weakness was 29% after parotidectomy while marginal mandibular nerve dysfunction occurred after 12% of submandibular excisions. Both procedures were highly effective in permanently relieving the symptoms of sialadenitis.

CONCLUSIONS

Parotid sialadenitis is infrequently associated with stones and tends to run a longer course before surgical intervention is necessary. Submandibular sialadenitis usually presents earlier, is secondary to calculi and requires early intervention.

Parotid and neck metastases from cutaneous squamous cell carcinoma of the head and neck

BACKGROUND

Approximately 5% of cutaneous squamous cell carcinomas (SCC) metastasize to regional nodes. Nodal involvement may be more common for cutaneous squamous cell carcinomas of the head and neck, but few large series have reported clinical outcome after treatment of parotid gland and neck metastases from these cancers.

PATIENTS AND METHODS

A combined retrospective/prospective study of patients treated between 1983 and 1994 was performed. There were 69 men and 6 women, with a median age of 67 years. Twenty-nine patients had neck metastases, and 33 had parotid gland metastases, while 13 patients had involvement at both sites. Of the 75 patients, 68 were treated surgically and 50 received postoperative radiotherapy.

RESULTS

The facial nerve was sacrificed totally in 6 patients and partially in 9. Histologic extranodal spread was present in 48 (71%) of all surgically treated patients. Among 61 patients followed up to recurrence, or for greater than 12 months, 26 (43%) developed recurrence--12 in the parotid gland, 7 in the neck, and 7 in both sites. Multiple recurrences were common and occurred at a median of 8 months after surgery. Positive surgical margins were associated with poorer local disease control (P < 0.05). Cumulative survival at 5 years was 61%, but only 15 of 70 evaluable patients (21%) were eligible for follow-up at this time. Neck involvement with or without parotid gland disease was associated with an increased risk of distant metastases, but this was not statistically significant. Postoperative radiotherapy was not associated with improved disease control.

CONCLUSION

Cutaneous, metastatic SCC involving the parotid gland and neck is an aggressive disease with a tendency to an infiltrative growth pattern and multiple recurrences. More aggressive surgery may be justified to reduce the incidence of regional failure after parotidectomy and neck dissection.

Evaluation of 107 therapeutic and elective parotidectomies for cutaneous melanoma

A total of 107 patients with cutaneous melanoma had parotidectomies performed by one surgeon over a 6-year period. Twenty-five parotidectomies were therapeutic and 82 were elective. All elective and 18 therapeutic operations entailed superficial lobectomy, and there were 4 total and 3 subtotal therapeutic operations. The facial nerve was completely preserved in 97 operations, partially sacrificed in 8, and totally sacrificed in 2. Neck dissection accompanied all but 1 parotidectomy. The most common postoperative complication was facial nerve dysfunction. A total of 33 of 82 patients had lower lip weakness between 6 months and 5 years after elective parotidectomy. Lymph nodes were pathologically positive in the parotid gland in 27 patients and in the neck in 15 patients. Ten patients had both parotid and neck metastases. Among patients with positive melanoma in the parotid gland who were observed for at least 1 year, 16 received adjuvant postoperative radiotherapy (550 cGy x 5 fractions) and 9 did not. Parotid recurrences developed in 1/16 irradiated and 4/9 nonirradiated patients but this difference was not significant. Overall melanoma-specific survival at 5 years was 64%, with nodal involvement in the neck or parotid gland significantly worsening prognosis (40% survival at 5 years). The roles of elective lymphadenectomy and adjuvant radiotherapy are now being examined in prospective randomized clinical trials.