SENSATION RECOVERY IMPROVED BY GREAT AURICULAR NERVE PRESERVATION IN PAROTIDECTOMY: A PROSPECTIVE DOUBLE-BLIND STUDY

Great auricular nerve conservation and parotidectomy for tumor

OBJECTIVE

To describe the key technical points for preserving the great auricular nerve during parotidectomy for tumor, and to discuss the literature regarding the benefits, limitations and indications for nerve-sparing surgery. Data suggested that great auricular nerve preservation should be discussed in the preoperative consultation, attempted intraoperatively and mentioned in the operative report once parotidectomy completed.

Impact of great auricular nerve sacrifice on sensory disturbance after parotidectomy

PURPOSE

To investigate the association between great auricular nerve (GAN) sacrifice during parotidectomy and postoperative sensory disturbance.

MATERIALS AND METHODS

Patients who underwent parotidectomy between November 2016 and May 2020 at a single academic institution were included in this retrospective chart review. Operative notes were reviewed to determine incidence of GAN sacrifice. Prevalence of patient-reported sensory complaints in the GAN distribution and time to spontaneous resolution of symptoms were assessed.

RESULTS

Of 305 parotidectomy patients, 111 (36.4%) endorsed complaints of postoperative sensory disturbances in the GAN distribution typically characterized by numbness or shooting pains. GAN sacrifice was present in 9 (8.1%) of 111 patients who experienced sensory disturbances compared to 9 (4.6%) who reported no sensory disturbances (p > 0.05). Twenty-five patients (32.5%) experienced spontaneous resolution of symptoms at their most recent follow-up at a mean of 6.2 months after onset of symptoms. Of those that experienced a sensory disturbance, GAN preservation was not significantly associated with likelihood of spontaneous recovery (p > 0.05).

CONCLUSIONS

We report the largest series to date of post-operative sensory disturbance in parotidectomy patients as it relates to intraoperative GAN sacrifice. Although the relationship between GAN sacrifice and the incidence of postoperative sensory disturbance and its subsequent resolution were not significant, we continue to advocate for GAN preservation to reduce incidence of postoperative sensory disturbances.

Minor Parotidectomy Complications: A Systematic Review

OBJECTIVES

To report descriptive statistics for minor parotidectomy complications.

METHODS

A systematic review was performed, selecting 235 studies for analysis. The incidence of complications was tabulated, and descriptive statistics calculated. Outlier studies, 1 standard deviation above the mean, were reexamined to determine potential causal factors for each complication. All studies were examined for statistically significant differences for any potential causal factor.

RESULTS

The pooled incidence of minor complications reported were hematoma 2.9% (95% confidence interval [CI]: 2.4-3.5), wound infection 2.3% (95% CI: 1.8-2.9), sialocele 4.5% (95% CI: 3.5-5.7), salivary fistula 3.1% (95% CI: 2.6-3.7), flap necrosis 1.7% (95% CI: 1.1-2.5), scar issues 3.6% (95% CI: 2.4-5.4), numbness 33.9% (95% CI: 25.6-43.4), and deformity 11.8 (95% CI: 6.9-19.5). Implants result in more wound complications, such as hematoma, sialocele, or salivary fistula. Sialocele and salivary fistula appear more frequently after less extensive parotid surgery, whereas hematoma, wound infections, flap necrosis, and aesthetic considerations are worse with more extensive resections.

CONCLUSIONS

Minor parotidectomy complications are more frequent than generally assumed and related to certain factors that should be investigated. Laryngoscope, 131:571-579, 2021.

Modified Postauricular Incision for Preservation of the Lesser Occipital Nerve and the Great Auricular Nerve in Ear Surgery

OBJECTIVE

To describe the feasibility of preserving the lesser occipital nerve (LON) and the great auricular nerve (GAN) in postauricular incision in ear surgery.

METHODS

The distribution of the LON and the GAN was first identified in human cadavers. Then a clinical study was performed in 34 patients who underwent middle ear surgery between September 2016 and January 2017. Patients were divided into the conventional incision group and the modified incision group, according to incision types, and underwent sensory testing and subjective evaluation of auricular numbness after surgery at different times.

RESULTS

Most frequently, the auricular branches of the LON went into the postauricular groove at the same height of inferior crus of antihelix. The vertical dimension from the intersection of the highest auricular branch of the GAN and postauricular groove to intertragic notch ranged from 5.7 to -4.2 mm. Preservation of the LON and the GAN reduced sensory loss in the modified incision group compared to the conventional incision group.

CONCLUSION

Preservation of the LON and the GAN with modified postauricular incision can reduce postoperative auricular numbness.

Effects of an antiadhesive agent on functional recovery of the greater auricular nerve after parotidectomy: a double-blind randomized controlled trial

PURPOSE

Periauricular sensory deficit occurs frequently after parotidectomy even in cases with preservation of the greater auricular nerve (GAN). This study was performed to evaluate the effects of antiadhesive agent in functional recovery of the GAN after parotidectomy.

METHODS

Ninety-eight patients undergoing partial parotidectomy for benign parotid tumors were prospectively enrolled in this multicenter, double-blind randomized controlled study and randomly assigned to either the study or control group. Antiadhesive agent was applied in the study group. The results of sensory tests (tactile, heat, and cold sensitivity) and a questionnaire on quality of life (QoL) were acquired at postoperative 1, 8, and 24 weeks after surgery. Clinical parameters, and the results of the sensory tests and the questionnaire, were compared between the two groups.

RESULTS

A total of 80 patients were finally enrolled. On sensory evaluation, tactile sensation and warm sensation in the ear lobule, and warm sensation in the mastoid area, showed significant improvement at 24 weeks postoperatively in the study group. There were no significant differences between the two groups on any questions in the QoL questionnaire, at any follow-up time point.

CONCLUSIONS

Antiadhesive agents have some positive effects on functional recovery of the GAN after parotidectomy. Therefore, applying antiadhesive agents after parotidectomy can reduce discomfort in patients.

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

PURPOSE

Benign parotid tumors are adequately treated with partial parotidectomy, which is often performed under general anesthesia (GA). We have reported our preliminary results on the feasibility to perform parotidectomy under local anesthesia (LA). We hereby present our accumulated experience of partial parotidectomy under LA to further consolidate its feasibility, efficacy and safety in a larger series.

MATERIALS AND METHODS

Case series review was carried out using our own center patients' database. 50 patients with parotid tumors were treated with partial parotidectomy under LA, using a retrograde nerve dissection approach from January 2006 to October 2016. The inclusion criteria encompassed mobile parotid nodules primarily operated after non-suspicious fine-needle aspiration cytology. Their demographics, complications and outcomes were evaluated.

RESULTS

No procedure required conversion to GA. There were 48 benign tumors and 2 lymphomas based on the histopathologic examination. The commonest pathologies were pleomorphic adenoma (40%), Warthin's tumor (38%) and cyst (8%). The mean tumor size was 2.68 ± 1.5 cm and the mean operative time was 91.5 ± 34.7 min. Forty-two operations were done as day cases. Ten (20%) patients suffered from transient ear lobe numbness and two (4%) patients had sialocele. Transient facial palsy occurred in 2(4%) patients while another patient (2%) had persistent House-Brackmann grade II facial palsy. No tumor recurrence was noted during follow-up period.

CONCLUSIONS

Partial parotidectomy adopting a retrograde nerve dissection under LA is feasible and minimally invasive in treating benign parotid tumors. It can avoid the adverse effects of general anesthesia and promote day surgery or minimize hospital stay.

Parotidectomy combined with identification and preservation procedures of the great auricular nerve

CONCLUSIONS

We found that the great auricular nerve (GAN) passes at the median (m) point between the tips of the mandibular angle and mastoid process. We also established the GAN definitive line using this point for rapid identification of the trunk of the GAN and systematic parotidectomy combined with procedures for identification of the GAN, elevation of the skin flap, and exposure of the parotid capsule, which showed a high rate of preservation of the nerve and the lobular branch.

OBJECTIVE

The aim of this study was to improve parotidectomy and the rate of preservation of the GAN.

METHODS

This study comprised 74 consecutive patients who were scheduled to have parotidectomy for benign tumors at our department between November 2011 and April 2014. We examined whether our GAN definitive line including the m point was useful to identify the trunk of the GAN and whether anterograde dissection of the nerve could be performed simultaneously with skin flap elevation and exposure of the parotid capsule and contributed to preservation of the trunk to the lobular branch.

RESULTS

The trunk was identified under the GAN definitive line drawn preoperatively in 97.3% of cases (72/74). Combined surgery was successfully performed with a 95.9% (71/74) preservation rate of the GAN including the lobular branch.

Great auricular nerve preservation during parotidectomy for benign tumors

The great auricular nerve, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the sternocleidomastoid muscle. In few years, many experiences by different authors concerning the issue of great auricular nerve integrity during parotidectomy were published in the literature. The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery.

Great auricular nerve preservation in parotid gland surgery: Long-term outcomes

OBJECTIVES/HYPOTHESIS

To assess sensory outcomes and quality of life (QoL) in two groups of patients with and without great auricular nerve (GAN) preservation during parotidectomy.

STUDY DESIGN

Retrospective chart review.

METHODS

The posterior branch of the GAN was preserved in 42 patients (group A) and sacrificed in 13 (group B). Tactile, heat, and cold sensitivities were investigated by dividing GAN territory into seven areas. Comparisons between operated (OS) and nonoperated sides (NS) within each group, and between the OS of the two groups were made. The QoL questionnaire was administered.

RESULTS

In group A, normal tactile, heat, and cold sensitivities ranged from 16.7% to 66.7%, 11.9% to 73.8%, and 21.4% to 81%, respectively, in different OS areas. Significant differences between OS and NS were found, except for the preauricular superior area. In group B, normal tactile, heat, and cold sensitivities ranged from 0% to 61.5%, 0% to 53.8%, and 7.7% to 76.9%, respectively, in different OS areas. Significant differences between OS and NS were found except for the preauricular superior (tactile sensitivity), and preauricular superior and helix/concha areas (cold sensitivity). Comparing the OS tactile and thermic sensitivities between the two groups, only the lobule area showed differences. The preauricular inferior area was different only for heat. The QoL questionnaire showed different hypoesthesia extension between the two groups. All other items were comparable.

CONCLUSIONS

Sensory deficits are commonly reported despite GAN preservation. Lobule and preauricular inferior areas showed differences in terms of tactile and thermic sensitivities, with better outcomes in group A. QoL seems tolerable despite GAN sacrifice.

LEVEL OF EVIDENCE

4

Preservation of greater auricular nerve during parotidectomy: sensation, quality of life, and morbidity issues. A systematic review

BACKGROUND

Our objectives were to assess the evidence of preservation of the greater auricular nerve in parotidectomy with regard to morbidity and quality of life.

METHODS

This was a systematic review. Inclusion criteria were: English literature, prospective and retrospective studies. Exclusion criteria were: single case reports, "teaching" reviews. Outcome measures were: tactile sensation, pain, thermal sensitivity, and quality of life.

RESULTS

Although quality of life does not seem to be adversely affected when the greater auricular nerve is sacrificed, preservation of the posterior branch was recommended in 8 studies. When preserving the nerve, the incremental operative time increase is no more than 10 to 5 minutes after a rapid learning curve.

CONCLUSIONS

There is level Ib evidence that preservation of the greater auricular nerve minimizes the postoperative sensory disturbance and should be considered whenever tumor clearance is not compromised. There is no evidence that overall quality of life is affected when the greater auricular nerve is sacrificed.

Parotidectomy under local anesthesia--report of 7 cases

OBJECTIVE

Parotidectomy is usually carried out under general anesthesia. We reported our early experience of performing parotidectomy under local anesthesia.

STUDY DESIGN

Case series reviewed.

SETTING

Head and neck services of a regional hospital. PATIENTS, INTERVENTION, AND RESULTS: Seven patients underwent parotidectomy under local anesthesia. The indications were high risk for general anesthesia due to co-morbidity in 2 patients and personal preference for the rest. The operations were performed by retrograde facial nerve dissection after superficial cervical plexus block and incision wound infiltration with local anesthetics. There was no conversion to general anesthesia. Six operations were carried out in the setting of ambulatory procedure and were discharged on the same day. Transient mild facial paresis occurred in 2 patients.

CONCLUSION

Parotidectomy under local anesthesia can be conducted successfully and avoid the adverse effect of general anesthesia.

Long-term great auricular nerve morbidity after sacrifice during parotidectomy

OBJECTIVES/HYPOTHESIS

To clarify the extent and patient perspectives of great auricular nerve (GAN) morbidity and recovery after nerve sacrifice during parotidectomy 4 to 5 years after surgery.

STUDY DESIGN

Prospective series.

METHODS

Twenty-two patients who underwent parotidectomy with GAN sacrifice and were previously studied for GAN sensory outcome during the first postoperative year. We performed light touch sensation tests on each patient to develop an ink map representing anesthesia and paresthesia in the GAN sensory territory; patients also completed an outcomes questionnaire.

RESULTS

Nineteen (86%) of 22 patients completed follow-up. One patient completed the questionnaire over the phone. The prevalence and average areas of anesthesia and paresthesia decreased since the first postoperative year according to sensory testing and patient scoring. At 4 to 5 years, 47% (9 of 19) of the patients had anesthesia, 58% (11 of 19) had paresthesia, and 26% (5 of 19) had neither anesthesia nor paresthesia during sensory testing. Patients reported that the GAN dysfunction brought them no to mild inference with their daily activities. At a mean point of 2 years, 70% (14 of 20) patients felt that their sensory symptoms had either completely abated or stabilized.

CONCLUSIONS

The posterior branch of the GAN should be preserved if it does not compromise tumor resection. If this is not possible, the patient and surgeon should be comforted in that only minor, if any, long-term disability will ensue. Laryngoscope, 2009.