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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical management and side effects of parotid gland surgery for benign lesions: a retrospective analysis of our experience from 2012 to 2021

Surgery is the treatment of choice for tumours in the parotid gland. We evaluated complications following parotid surgery. We conducted a retrospective study on 554 patients undergoing parotid surgery for benign parotid tumours from 2012 to 2021. We analysed complication rates between extracapsular dissection (ECD) and superficial parotidectomy (SP). We found 19 capsular ruptures in patients undergoing ECD (5.34%) and five among those undergoing SP (2.52%) [p < 0,05]; 16 cases of temporary facial paralysis among those undergoing ECD (4.49%) and 35 in patients undergoing SP (17.67%) [p < 0,05]; and eight instances of permanent facial nerve paralysis in patients undergoing ECD (2.25%) [p > 0,05] and 13 in patients undergoing SP (6.56%). Among the mid-term complications described were: 22 salivary fistulas among patients operated with ECD (6.18%) [p > 0,05] and 17 in patients with SP (8.58%) 17 sialoceles in those who underwent ECD (4.77%) and seven with SP (3.53%) [p > 0,05]. Regarding late complications, we found: surgical wound dehiscence, pathological scarring (keloid), Frey's syndrome, and recurrence, which affected 45 patients with ECD (12.64%) and 21 with SP for dehiscence (10.6%) [p < 0,05]; 28 keloids in patients with ECD (7.86%) and 15 in patients with SP (7.57%) [p > 0,05]; 12 cases of Frey's syndrome in patients with ECD (3.37%) and 36 with SP (18.18%) [p < 0,05]; and finally 22 recurrences in patients who underwent ECD (6.18%) and 13 in patients who underwent SP (6.56%) [p > 0,05], including 30 in the 273 patients with pleomorphic adenoma and five in the 214 patients with Warthin's tumour. We can conclude that the onset of the different complications after parotid gland surgery are related to the surgery performed. Our data confirm that there is a tight relationship between type of surgery performed and type of complication.

Transoral approach to accessory parotid tumours: case series and literature review

Accessory parotid tumours are rare, accounting for less than 10% of parotid neoplasms. Although similar tumours affect both the accessory parotid and parotid, accessory parotid tumours are associated with higher rates of malignancy. Surgery is first line management. Standard surgical management involves a similar approach to superficial parotidectomy, despite the anterior location of these lesions. This approach requires extensive subcutaneous access and facial nerve dissection and therefore, poses significant risk. It can also result in poor cosmetic result due to scarring and Frey's Syndrome. On the contrary, a transoral approach to reduces the risk of cosmetic deformity, reduces recovery time and does not increase risk to the facial nerve. We present a case series of patients with accessory parotid masses, which have been successfully excised transoral and without endoscopic assistance.

Management of benign parotid tumors. What can we learn from our experience?

AIM

Parotid gland is the most common location for salivary gland tumors, more commonly pleomorphic adenoma and Warthin's tumor. Types of parotid surgery include superficial parotidectomy (SP), partial superficial parotidectomy (PSP), total conservative parotidectomy (TCP), enucleation (E), extracapsular dissection (ECD), and are related to different incidence of complications. The choice depends on tumors localization, dimension and histology. The aim was to compare complications rate such as facial and great auricular nerve impairment and Frey syndrome according to type of surgery performed.

MATERIALS AND METHODS

We retrospectively review the management of 116 benign tumors of the parotid gland treated between January 2004 and January 2020 at our Department.

RESULTS

Most frequent complication observed was a GAN deficiency (22.41%), permanent in 13% of cases. Post-operative facial nerve impairment was observed in 19 patients (persistent only in 1 case). Only Frey syndrome (4,31% of cases) seemed to be related to type of surgery (p<0.05) resulting more frequent in the group of patients that underwent "classical" parotidectomy, while facial nerve impairment, even if more frequent in this cases, did not statistically correlated with operative technique (p=0.054).

CONCLUSIONS

Once experience is gained, in order to reduce post-operative morbidity extracapsular dissection is a reliable technique in the management of these neoplasms, even if attention has to be paid particularly in the removal of superficial masses "emerging" from the parenchyma. PSP is an alternative to SP, while CTP has to be reserved to selected cases ot tumors arising in the deep lobe.

KEY WORDS

Benign tumor, Extracapsular dissection, Enucleation, Facial nerve Parotid gland, Parotidectomy, Superficial parotidectomy.

Efficacy of SMAS flap technique to prevent Frey's syndrome and aesthetic outcomes. A retrospective cohort analysis

AIM

The aim of this retrospective cohort study was to evaluate the efficacy of Superficial Musculoaponeurotic System (SMAS) flap technique to prevent Frey's Syndrome (FS) and improve aesthetic outcomes following superficial parotidectomy.

MATERIALS AND METHODS

A total of 140 patients were treated between January 2003 and December 2018 at the Maxillofacial Unit of Magna Graecia University of Catanzaro with Superficial Parotidectomy (SP) for benign tumor and divided in two groups: Group 1 (78 patients) underwent SMAS flap reconstruction of the parotid lodge through a modified facelift incision and Group 2 (62 patients) underwent to SP without the use of SMAS interposition through a Redon type incision.

RESULTS

Significant statistical difference concerning FS, transient facial nerve injury, facial paralysis, salivary fistula, haematoma and skin deepness were found between Group 1 and Group 2, (0,00% vs 6,45% [p < 0,036], 2,56% vs 16,12% [p = 0,005], 0,00% vs 9,67% [p= 0,006], 1,28% vs 9,67% [p= 0,044], 1,28% vs 19,35% [p = 0,0002]) respectively. No significant statistical differences between the two groups were observed about wound infections (3,84% vs 8,06% [p= 0,466]).

DISCUSSION

SP represents the gold standard for the surgical treatment of benign tumors of the parotid gland greater than 3,5 cm in size involving superficial portion of the gland, for the low rate of recurrences over time and lower incidence of transient or permanent facial paralysis to which this technique leads. However, SP is not free from other complications such as FS, haematoma, salivary fistula and aesthetic results like facial contour deformity due to surgical site depression and visible scar. A reconstructive technique to reduce the impact of complications after SP is the SMAS flap because its preparation is easy, contextual to the parotidectomy and increases a little the surgical time.

CONCLUSIONS

This study highlights the advantages of SMAS flap technique in reducing complications following parotid surgery, particularly FS, and in improving the quality of life.

KEY WORDS

Frey's Syndrome, Minor test, Parotid benign tumor, SMAS flap, Superficial parotidectomy.

Frey's Syndrome

The history of Frey's syndrome is explored together with its physiopathological and anatomical basis. A study of 19 cases of parotidectomy in 15 patients is reviewed and the results of 17 tympanic neurectomies presented.

Complications after parotid gland surgery Our experience

AIM

Complications after parotid surgery include deficit of the facial nerve, wound complications, as sialocele and salivary fistula, and Frey syndrome; the goal of this study was to evaluate the relationship between the type of parotid surgery performed and the incidence of each of these complications.

MATERIAL OF STUDY

A total of 184 patients were evaluated and 158 were included in the study. Four different kinds of intervention were made: extracapsular dissection, partial superficial parotidectomy; superficial parotidectomy and total parotidectomy. The incidence of each complication was studied and correlated to the type of surgery performed. Statistical analysis was done using the chi-square test of independence.

RESULTS

From all cases examined, 86 patients developed facial nerve complications with 59 minor asymmetry, 19 partial weakness and 8 complete weakness. Forty patients had wound complications, 28 sialocele and 12 salivary fistula. Sixteen patients developed Frey syndrome.

DISCUSSION

Facial nerve complications and Frey syndrome were significantly related to superficial or total parotidectomy, differently extracapsular dissection and partial superficial parotidectomy had more cases of wound complications.

CONCLUSION

The kind of complications that occur after parotid surgery depends on surgery performed. Chi-square test has a statistically significant result and confirms this kind of relationship (P <.0001).

KEY WORDS

Facial nerve, Parotid glands, Parotidectomy.

Modified superficial parotidectomy: Preserving both the great auricular nerve and the parotid gland fascia

Objective

To reduce the incidence of sensory deficits and Frey's syndrome by modifying the traditional superficial parotidectomy.

Study Design

After raising the skin flap, the parotid gland fascia (PGF) was elevated to form a posterior pedicle fascial flap and then was replaced after the gland removal. The great auricular nerve (GAN) that runs within the PGF was not separated, so both the GAN and the PGF were preserved. Before this modification, the GAN and PGF were examined anatomically. The complication rates in the modified and control groups were compared.

Results

1) The GAN, which runs within the thick and pycnotic PGF, trifurcates into postauricular, preauricular and lobule branches. The modification could be carried out practically based on the anatomy study. 2) Long-term sensory deficit was encountered in 13.3% of the control group, but 0% in the modified one. Frey's syndrome was suffered by 66.7% and 16.7% cases in the control and modified group respectively. The incidence of other complications was not significantly different.

Conclusion

Our modification is practical. It decreases the complications significantly. EBM rating: B-3b

Frey's syndrome after superficial parotidectomy: role of the sternocleidomastoid muscle flap: a prospective nonrandomized controlled trial

BACKGROUND

The prevalence of Frey's syndrome (FS) after superficial parotidectomy in correlation to the sternocleidomastoid muscle flap (SCMMF) interposition is analyzed.

METHODS

A prospective nonrandomized controlled multicenter trial included 130 patients. During superficial parotidectomy, SCMMF was dissected, if excised specimens' volume exceeded 25 mL (SCMMF group). Follow-up examinations took place after 6, 12, and 24 months and included a Minor's test.

RESULTS

SCMMF was dissected in 30 (23.1%) patients. A total of 104, 80, and 68 patients completed the 1st, 2nd, and the 3rd follow-up, respectively. FS was detectable with nonvarying prevalence (46.3%, 45.6%, and 43.4%, respectively) during follow-up. The prevalence was higher in the SCMMF group (59.9%) than in the non-SCMMF group (41.8%; P = .92). The sweating area increased during follow-up (P = .12). Overall, 89.5% of patients characterized FS as not disturbing after 2 years.

CONCLUSIONS

FS occurred with a steady and high prevalence after superficial parotidectomy. In particular, SCMMF did not lower the risk of FS.

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

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

Treatment of postparotidectomy Frey syndrome with the interposition of temporalis fascia and sternocleidomastoid flaps

OBJECTIVES

This study was performed to evaluate the effectiveness of overlapping the temporalis fascia flaps (TFFs) and the sternocleidomastoid muscle flaps (SCMFs) as physical barriers to treat established Frey syndrome and concavity after parotidectomy.

STUDY DESIGN

We retrospectively reviewed 17 patients who underwent corrective procedures with simultaneous TFF and SCMF interposition for the treatment of Frey syndrome. The affected areas of the cheek skin were identified with starch-iodine tests. The facial contours of the patients were classified as bilaterally symmetric (BS), with a slightly shallow (SS) contour on the surgical side, or with a conspicuously shallow (CS) contour on the surgical side.

RESULTS

The sample was followed up for a mean of 22 months. The average area of gustatory-sweating positive skin was reduced from 12.80 to 1.32 square centimeters postoperatively. The facial asymmetry secondary to parotidectomy was greatly improved.

CONCLUSIONS

The authors concluded that this technique was efficacious in ameliorating Frey syndrome and facial concavity secondary to parotidectomy.

Dissection with harmonic scalpel versus cold instruments in parotid surgery

BACKGROUND

The harmonic scalpel (HS) has been used successfully in several head and neck surgical procedures. Some authors highlighted its advantages in reducing operative time, blood loss, and damages to surrounding tissue. In our study, we compared the results obtained during parotidectomy using the HS with the traditional approach to determine the benefits of the HS.

METHODS

130 patients with benign parotid tumors were enrolled and randomized into two groups for this prospective study. 63 patients underwent HS parotidectomy, and 67 patients received a parotidectomy using cold instruments and bipolar electrocautery hemostatic control (CI). 20 HS and 2 CI patients did not meet the inclusion criteria requirements, and were excluded.

RESULTS

The admission time was significantly shorter in the HS group than the CI group (3.9 ± 1.2 days and 4.7 ± 1.4 days, respectively, p < 0.01). In the early post-operative period, 84% of HS patients and 60% of CI cases showed no facial nerve impairment (p = 0.01). Significantly more CI patients than HS patients showed the onset of Frey's syndrome (29% and 9%, respectively, p = 0.01). Multivariate stepwise regression analysis confirmed the reduction in admission length (Odds Ratio (OR): 0.62; p = 0.02) and the lower risk of Frey's syndrome (OR: 0.29; p = 0.04) in HS compared to CI parotidectomies.

CONCLUSIONS

In parotid surgery, the HS is useful in preventing Frey's syndrome and reducing early transitory facial nerve dysfunction and admission times, and results in decreased medical costs and increased quality of life.

Use of irradiate animal pericardium membrane for prevention of Frey's syndrome after parotidectomy

BACKGROUND

Frey syndrome is a common complication that appears few months after parotid surgery with flushing and sweating of the parotid-temporal area during mastication. It presumably originates from an aberrant nervous regeneration in which the parasympathetic fibers of the parotid gland would combine themselves with the sympathetic fibers of the sweat glands and with the cutaneous vessels.

AIM

In the present study we analyze the effectiveness of a collagenous membrane derived from animal pericardium (APM) to prevent Frey's syndrome after parotidectomy.

MATERIALS AND METHODS

We studied a total of 40 patients with benign tumors of the parotid gland, including 30 patients with pleomorphic adenoma, 7 patients with Warthin tumor and 3 with basal cells adenoma. The patients were divided into 2 groups: group 1 (experimental n=20) executed superficial parotidectomy with replacement of bovine pericardial matrix (BPM); group 2 (control n=20) underwent superficial parotidectomy followed by reposition of superficial musculoaponeurotic system (SMAS) flap. All patients were questioned over their subjective symptom and tested with Minor's test after 12 months from the intervention and introduced in a follow-up of 3 years.

RESULTS

Subjectively Frey syndrome was referred in 5% of patients in group 1 and in 10% in group 2, while 0 cases were observed in group 1 after the starch-iodine test, 2 cases in group 2 (10%).

CONCLUSIONS

Considering the present results, although this study needs further implementation, we can affirm that BPM is a valid option in preventing Frey's syndrome whereas SMAS flap is not available.

Frey-Syndrom nach lateraler Parotidektomie

BACKGROUND

Gustatory sweating is a common complication of parotid surgery.

PATIENTS AND METHODS

In order to evaluate the incidence of Frey's syndrome following superficial parotidectomy, 69 patients who underwent surgery due to adenoma were studied. Forty-three patients (62%) suffered from gustatory sweating following superficial parotidectomy, and 33 of them requested treatment. Nineteen patients felt that their quality of life had been decreased by the symptoms.

RESULTS

Minor's starch iodine test proved that 85% of the patients who did not notice Frey's syndrome after surgery actually had a subclinical manifestation. Eight patients were successfully treated with intracutaneous injections of botulinum toxin A. Within 1 week gustatory sweating disappeared.

CONCLUSION

Frey's syndrome is present in almost all patients following superficial parotidectomy and there is a strong need for treatment. Intracutaneous injection of botulinum toxin A is an effective treatment in severe cases of the syndrome.

Frey's syndrome: case report

Frey's syndrome is characterized by facial sweating and flushing in the parotid area when saliva is stimulated. It usually results from damage to the auriculotemporal nerve during parotidectomy.

[Effectiveness of pedicled sternocleidomastoid muscle flap in repairing defect after parotidectomy]

OBJECTIVE

To investigate the effectiveness of pedicled sternocleidomastoid muscle flap in repairing defect after parotidectomy by comparing with direct suture.

METHODS

The clinical data were retrospectively analyzed, which were from 73 patients with parotid tumor undergoing parotidectomy between January 2002 and April 2010. After parotidectomy, defects were repaired with pedicled sternocleidomastoid muscle flap in 38 cases (flap group) and with direct suture in 35 cases (control group). There was no significant difference in gender, age, disease duration, tumor location and size between 2 groups (P > 0.05). Meanwhile the complications, such as local intercession deformity, Frey's syndrome and parotid gland fistula were observed.

RESULTS

In flap group, the flaps were all alive and incisions healed by first intention; in control group, all incisions healed by first intention. All patients were followed up 6-98 months and no tumor recurred. There was significant difference in local intercession deformity between 2 groups (chi2 = 53.202, P = 0.000). The parotid gland fistula was found in 1 case (2.6%) of the flap group and in 8 cases (22.8%) of the control group, Frey's syndrome was found 1 case (2.6%) of the flap group and in 20 cases (57.1%) of the control group, showing significant differences between 2 groups (P < 0.05).

CONCLUSION

The use of pedicled sternocleidomastoid muscle flap for defect repair after parotidectomy can avoid the complications of local intercession deformity, Frey's syndrome, and parotid gland fistula.

[Successful treatment of diabetic gustatory hyperhidrosis with topical glycopyrrolate]

Gustatory hyperhidrosis is a condition characterised by excessive craniofacial sweating in relation to food intake and is associated with diabetic neuropathy. The existing guidelines for treatment of this condition include antiperspirants, oral anticholinergic treatment, ionophoresis, botulinum toxin injections and endothoracic surgery. In this case a patient with diabetes suffering from gustatory hyperhidrosis was treated successfully with topical glycopyrrolate, an anticholinergic agent applied directly on the affected area.

[Meta-analysis of surgical techniques for preventing Frey syndrome and a concave facial deformity after parotidectomy]

OBJECTIVE

To explore the curative effects on surgical methods for the prevention of Frey syndrome and a concave facial deformity after parotidectomy.

METHODS

A literature search was performed using the Wianfang Database, Chinese Biomedical Literature Disk Database, Chinese Digital Hospital Library and Chinese Scientific Journals Database of VIP from January 1989 to December 2008. Twenty-six Chinese language controlled studies involving surgical techniques for prevention of Frey syndrome and the concave facial deformity after parotidectomy were identified. Review manager 4.2 software was applied for Meta analysis.

RESULTS

Meta-analysis for surgical techniques to prevent symptomatic Frey syndrome, a positive starch-iodine test, and contour deformity, favored intervention with a cumulative odds ratio (OR) of 0.14 [95% confidence interval (CI), 0.07-0.25]; OR, 0.21 (95% CI, 0.17-0.26); and OR, 0.09 (95% CI, 0.04-0.19), respectively. There was a significant difference in the incidence of these complications between surgical treatment groups and control groups (Z = 6.42, Z = 13.70, Z = 6.43, all P < 0.05). The application of a sternocleidomastoid muscle flap decreased the incidence of symptomatic Frey syndrome (Z = 2.33, P < 0.05), positive starch-iodine test (Z = 7.48, P < 0.05) and contour deformity (Z = 7.78, P < 0.05). The application of acellular dermal matrix decreased the incidence of symptomatic Frey syndrome (Z = 6.02, P < 0.05) and positive starch-iodine test (Z = 5.72, P < 0.05) but did not decrease the incidence of contour deformity (Z = 1.27, P > 0.05).

CONCLUSIONS

Meta-analysis of operative techniques to prevent symptomatic Frey syndrome, a positive starch-iodine test, and facial asymmetry suggests that such methods are likely to reduce the incidence of these complications and improve the quality of life after parotidectomy.

Parotidectomy: a review of 112 patients treated at a teaching hospital in Pakistan

OBJECTIVE

The purpose of this study was to analyze the clinical presentation, histopathology and complications following parotid surgery.

METHODS

We retrospectively reviewed the charts of 112 patients who underwent parotidectomy from January 2000 to February 2010. Data including age, sex, clinical signs and symptoms, histology and complication were collected from medical records.

RESULTS

Of the total, 82 (74%) had benign lesions, 30 (36%) had malignant tumors. The most common benign tumor was pleomorphic adenoma (57%), and the most common malignant tumor was mucoepidermoid carcinoma (16%). Analysis of the correlation between fine-needle aspiration cytology and final histology revealed that fine-needle aspiration sensitivity, specificity and accuracy to 86.6%, 97.6% and 94.6% respectively. The most common complication following parotidectomy was transient facial nerve palsy (18.7%).

CONCLUSION

Superficial parotidectomy is associated with a decrease incidence of transient facial nerve dysfunction compared with that of total parotidectomy. High grade or advanced tumour is a predictor of poor outcome which may require adjuvant therapy.

Management of Frey syndrome

Almost all patients who undergo parotidectomy will to some extent develop Frey syndrome (auriculotemporal syndrome or gustatory sweating) after surgery, because of aberrant regeneration of cut parasympathetic fibers between otic ganglion and subcutaneous vessels. However, only the minority of these patients needs treatment. The syndrome consists of gustatory sweating, flushing, and warming over the preauricular and temporal areas. Thick skin flap and partial superficial parotidectomy are the most important techniques to minimize the risk of developing symptomatic Frey syndrome. Intracutaneous injection of botulinum toxin A is an effective, long-lasting, and well-tolerated treatment of Frey syndrome. If recurrence occurs, the treatment can be repeated.

[Clinical application of acellular dermal matrix to prevent gustatory sweating syndrome]

OBJECTIVE

To evaluate the clinical effect of acellular dermal matrix (ADM) on preventing Frey syndrome after parotidectomy.

METHODS

Fifty-seven patients were randomized into two groups, ADM group (30 patients) receiving acellular dermal matrix and control group (27 patients) without application of acellular dermal matrix. The incidence of Frey syndrome was evaluated after operation.

RESULTS

The incidences of Frey syndrome were 13.3% in ADM group and 55.6% in control group. There was significant difference in Frey syndrome incidence between the two groups (P < 0.01).

CONCLUSIONS

The application of acellular dermal matrix could effectively prevent Frey syndrome after parotidectomy.

Parotidectomy: ten-year review of 237 cases at a single institution

OBJECTIVE

To review a single surgeon's experience with parotidectomy with an emphasis on examining the appropriate use of partial superficial parotidectomy and the differences in early outcomes observed with the various types and extent of parotidectomy used.

STUDY DESIGN AND SETTING

A series of 237 patients who underwent parotidectomy over a 10-year period was reviewed.

RESULTS

Postoperative complications included facial nerve weakness (18%), sialocele (6.3%), wound infection (3.8%), hematoma (3.8%), and symptomatic Frey's syndrome (1.7%). More extensive surgical procedures, including complete superficial or total parotidectomy, were associated with a 2.7 times greater incidence of immediate postoperative facial nerve weakness compared with partial superficial parotidectomy.

CONCLUSION

Partial superficial parotidectomy is associated with a decreased incidence of transient postoperative facial nerve weakness compared with more extensive procedures such as complete superficial or total parotidectomy. Intraoperative frozen section was an accurate means of selecting patients for the partial superficial parotidectomy procedure.

SIGNIFICANCE

Partial superficial parotidectomy is an effective method for treating benign tumors confined to the superficial lobe.

The role of botulinum toxin in the management of head and neck cancer patients

PURPOSE OF REVIEW

In this review article different relevant applications of botulinum toxin type A are demonstrated in patients with head and neck cancer.

RECENT FINDINGS

Patients with head and neck cancers of different etiologies often suffer from disorders concerning their musculature (for example, synkinesis in mimic muscles) or gland secretion in the head and neck region. This leads to many problems and reduces their quality of life. The application of botulinum toxin type A can improve movement disorders like synkinesis following reconstructive surgery in patients with cancers of the parotid gland, spasms of the pharyngo-esophageal musculature following laryngectomies and disorders of the autonomous nerve system like hypersalivation, hyperlacrimation and pathological sweating.

SUMMARY

The application of botulinum toxin type A is a helpful and minimally invasive treatment option in different functional disorders improving the quality of life in patients with head and neck cancers of different etiologies. Side effects are rare.

Frey syndrome prevalence after partial parotidectomy

Introduction

Frey syndrome is a sequela observed after parotidectomy and the reported incidence varies enormously in the literature. Diagnosis is evaluated by presence of the classic triad of gustatory sweating, heating and flushing while feeding and documented by Minor starch-iodine test.

Aim

to evaluate the incidence of this syndrome in patients submitted to partial parotidectomy at Centro Otorrinolaringológico de Limeira, from 1994 to 2004, including presence of signs and symptoms and the surgical technique.

Material and method

fourteen patients undergoing partial parotidectomy with sternocleidomastoid muscle flap answered a questionnaire and were classified as positive or negative by Minor starch-iodine test in a clinical retrospective study.

Results

21% of the patients presented symptoms and positive iodine test.

Conclusion

only the patients presenting clinical symptoms had a positive test and the adopted surgical technique was efficient due to low incidence of the syndrome.

Incomplete auriculotemporal nerve syndrome--mimicry of oral allergy syndrome

Pollen allergies are commonly symptomatic as seasonal rhinoconjunctivitis. The majority of patients with pollen allergies develop an oral allergy syndrome due to cross-reactive homologous allergens in plant foods. Symptoms may vary from minor local oropharyngeal sensations and swelling to life threatening angioedema and glottis edema. We present the case of a 6-year-old male with suspected oral allergy syndrome who was referred for allergological work up. However, an incomplete auriculotemporal nerve syndrome was diagnosed, mimicking oral allergy syndrome.

[Frey syndrome secondary to submaxillectomy and botulinic treatment]

A case of Frey syndrome (FS) secondary to submaxillar gland exeresis is presented and the results of the treatment with botulinum toxin (BTX) type A. FS is a condition of sweating cheek and preauricular area during realtime as a sequel detected in about 20-60% of patients after parotidectomy. The clinical symptoms include swelling, flushing and hyperhidrosis. The treatment choice for this condition is intracutaneous injection of BTX type A which blocks acetylcholine release at the sweat glands. A 30-year-old man, with thyroid medullar carcinoma diagnosed in 2002 received 6 cicles of cisplatin plus doxorubicin previous to the thyroidectomy with anterolateral neck dissection. During surgery the left ramus marginalis mandibulae was damaged. Two years later the patient referred sweating in submaxillar region during meals. CT scan demonstrated the absence of left submaxillar gland. Minor's test disclosed the affected area and BTX type A was injected (2.5 U/cm2/17 points). A twenty-one-day control showed a 95% reduction of the affected skin area. Persistent efficacy was observed up to one year follow-up time when he was reinjected. The FS, also known as "gustatory hyperhidrosis", was probably first reported by M. Duphenix in 1757. Lucja Frey considered its physiopathology as a disorder of both sympathetic and parasympathetic innervation. In our case the FS was caused by a misdirected regeneration of postganglionic parasympathetic nerve fibers that arrised from the nervus lingualis rami ganglionares of the nervus trigeminus. After nerve injury the colinergic parasympathetic fibers seek out colinergic receptors--sympathetic receptors of the skin--innervating sweat glands and small skin vessels. All previous cases were located at masseter region post-parotidectomy. We have not found any description of FS in the submaxillary region. The self-assessed efficacy of the treatment with a hyperhidrosis disease severity scale revealed a very satisfied patient at 20 months follow-up after being injected twice with BTX type A.

Superficial parotidectomy as first choice for parotid tumours

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.

Lipomatous Lesions of the Parotid Gland

PURPOSE

Lipomatous lesions of the parotid gland are rare and seldom considered in the initial diagnosis of a parotid mass. We report our experience in the management of patients with lipomatous lesions affecting the parotid gland.

PATIENTS AND METHODS

Retrospective analysis of all parotidectomies performed for neoplastic lesions in the maxillofacial unit between 1975 and 2003 and patients with lipomatous lesions involving the parotid gland were identified; 638 parotidectomies were performed in this period on 629 patients in which 660 neoplasms were identified. Eight patients were found to have lipomatous lesions and form the basis of this study.

RESULTS

Lipomatous lesions accounted for only 1.3% of parotid tumors and occurred more frequently in males, at a ratio of 3 to 1. The most common presentation was that of a slowly enlarging, painless mass. Computed tomography scan was the most frequent imaging modality undertaken, and in 3 patients a diagnosis of a lipoma was made preoperatively. Seven patients underwent a superficial parotidectomy and 1 patient had a total conservative parotidectomy because of the deep lobe location of the mass. Five patients were found to have a focal lipoma and 3 patients had diffuse lipomatosis. There were no recurrences. Temporary facial nerve palsy and Frey's syndrome were the most frequent complications.

CONCLUSION

Lipomatous lesions accounted for only 1.3% of all parotid tumors. There were no specific distinguishing clinical features in our patients, and an accurate preoperative diagnosis was made in 3 patients based on imaging investigations. A well-circumscribed lipoma was more common than diffuse lipomatosis. Superficial parotidectomy was the treatment of choice and there were no recurrences in our series.

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.

[Frey's syndrome: report of three cases with two distinct etiopathogeneses]

Frey's syndrome is characterized by recurrent episodes of facial gustatory flushing and sweating (most frequent in adults) limited to the cutaneous distribution of the auriculotemporal nerve which, when injured, shows abnormal regeneration. The condition is relatively common in adults following nerve injury in parotid surgery but has rarely been reported in children as a sequel of perinatal birth trauma resulting from forceps assisted delivery. We report three patients with the same syndrome and two different causes. Two children had a history of forceps assisted delivery and one adolescent had undergone preauricular lymphadenectomy. This syndrome, which has more often been described by allergists and maxillofacial surgeons than by pediatricians, may pose problems of differential diagnosis with food allergy, leading to unnecessary exclusion diets. In the pediatric age group, Frey's syndrome is self limiting and does not require therapy if the diagnosis is correct.

The use of botulinum toxin in Frey's Syndrome

Frey's Syndrome, or gustatory sweating, occurs in over 50% of patients following superficial parotidectomy. In the vast majority of cases, these symptoms are not severe enough to require surgical treatment and can be effectively treated with topical anticholinergics and antihyperhydrotics. Patients with recalcitrant Frey's Syndrome can be treated by a variety of surgical procedures. However, the potential risks and side effects of these surgical procedures often outweigh the benefits. Botulinum toxin A has recently emerged as a popular treatment option for a number of head and neck conditions. The anticholinergic effects of Botox make it particularly suitable for the treatment of Frey's Syndrome. We report our experience.

Morbidity of parotid gland surgery: results 1 year post-operative

Patients operated on for parotid gland tumours were evaluated prospectively to study morbidity after this procedure. Nowadays, major complications such as recurrence of tumour and permanent facial nerve paresis are rare after primary surgery. Therefore, this study especially takes minor complications such as Frey's syndrome and sensory deficits into account. The study documents morbidity in 45 patients who completed a 1 year follow-up. Among those with primary benign tumours, we found no recurrences and no permanent paresis, nor did starch-iodine testing reveal any cases of Frey's syndrome. However, two patients who had previously been operated on multiple times did test positive for Frey's syndrome, as did two others after surgery for malignancy. Furthermore, we found that patients whose posterior branch of the great auricular nerve was sacrificed had a larger area of sensory deficit than those whose nerve was preserved. We conclude that the morbidity of parotid gland surgery can be reduced further by giving minor complications more attention.

Parotidectomy: Assessment of a surgical technique including facelift incision and SMAS advancement

BACKGROUND

Despite its proven safety and its relevance regarding the cosmetic outcome, the SMAS-lifting technique is not a routine procedure for many surgeons.

AIM

To compare the classical (subcutaneous flap and neck incision) with the SMAS-lifting techniques for parotidectomies from the patient's perspective.

PATIENTS AND METHODS

Both procedures are described, tricks are pointed out. In both procedures the posterior branch of the great auricular nerve was not preserved, hence the two procedures were not evaluated regarding sensitivity of the auricle and preauricular area. Forty consecutive patients were asked to classify their concerns before (1-4 months) and 1 year after surgery (10 classical technique and 30 SMAS-lifting technique).

RESULT

Before parotidectomy, patients were concerned in a decreasing order with the facial nerve function, the scar, the soft-tissue defect in the dorsal part of the cheek and Frey's syndrome. Following use of the classical technique, patients were concerned in decreasing order with the soft-tissue defect, the scar and Frey's syndrome. Following the SMAS technique, no one was concerned with the scar, Frey's syndrome, or the soft tissue defect although a slight asymmetry could still be noticed.

CONCLUSION

The SMAS-lifting technique might possibly appear to offer a new standard procedure for parotidectomy, except for malignant tumours or in obese patients.

Preservation of the superficial lobe for deep-lobe parotid tumors: a better aesthetic outcome

Deep-lobe parotid tumors are relatively uncommon. Most of these tumors present as external masses. They can also present in the oral cavity or oropharynx. Magnetic resonance imaging and ultrasound-guided fine-needle aspiration for biopsy and cytology have made it possible to establish a definitive diagnosis and identify the exact location of the tumor in almost all cases before surgery. Traditionally, deep-lobe tumors have been managed by a formal superficial parotidectomy and identification and preservation of the facial nerve, followed by removal of the deep lobe that contains the tumor Superficialparotidectomy is associated in most cases with periauricular depression secondary to a loss of volume, leading to variable aesthetic deformities. A complete parotidectomy is more likely to be associated with a larger aesthetic deficit secondary to a greater loss of tissue volume. The incidence of gustatory sweating is high after superficial parotidectomy, particularly in the early postoperative period. We hypothesize that if the superficial lobe is preserved, there is less likelihood of gustatory sweating because of the interposition of tissue between the skin and the cut ends of the secretomotor fibers. Approximately 80% of parotid tissue volume is made up of the superficial lobe, and therefore preservation of the superficial lobe should be associated with less postparotidectomy depression. Therefore, we decided to preserve the superficial lobe of the gland for deep-lobe tumors. Nine patients underwent deep-lobe parotidectomy with preservation of the superficial lobe over a 6-year period. Patients were studied prospectively with regard to technical difficulty, complications, and cosmetic outcome. Follow-up ranged from 12 months to 6 years. We did not experience any undue technical difficulty, and there were no cases of facial weakness. One patient developed gustatory sweating, which almost completely resolved over a 2-year period. There were no cases of post parotidectomy depression, and both patients and surgeons were satisfied with the cosmetic appearance. We present our technique and experience.

Parotid surgery: review of 107 tumors (1990-2002)

Tumors of the parotid gland are uncommon. We performed a retrospective study to analyze the clinical, diagnostic, and therapeutic features of a group of patients. We reviewed the clinical and the surgical records of a series of 109 patients who were recommended for surgery because of parotid tumors by the Plastic and Reconstructive Service of São João Hospital, Portugal, between 1990 and 2002. The following parameters were evaluated: age, sex, gland afflicted, symptoms, and duration of symptoms, diagnostic procedures, treatment methods, follow-up, and recurrences. Pleomorphic adenoma was the most common tumor (63.5%). In the majority of cases, fine-needle aspiration cytology was used. Swelling was the most frequent clinical finding. In 68.2%, superficial parotidectomy was performed. There were five cases of permanent facial palsy, and 10 patients developed Frey's syndrome. Recurrent disease was seen in six patients. For the majority of tumors, superficial parotidectomy is an effective treatment with acceptable morbidity.

Treatment of complications of parotid gland surgery

Although several reports in the literature have documented the surgical technique, and the oncological outcome achieved with parotidectomy, only a few articles have described the complications of parotid gland surgery and their management. Several complications have been reported in parotid surgery. We re-classified the complications of parotidectomy in intra-operative and post-operative (early and late). The commonest complications after parotidectomy are temporary or permanent facial palsy and Frey's syndrome.

Severity of compensatory sweating after thoracoscopic sympathectomy

BACKGROUND

Compensatory sweating is a well-known side effect after sympathectomy for hyperhidrosis. It is often claimed to correlate with the extent of sympathectomy, but results from the literature are conflicting, and few have actually considered differences in the intensity of compensatory sweating.

METHODS

A total of 158 patients underwent thoracoscopic sympathectomy for primary hyperhidrosis or blushing, or both. Sympathectomy was performed bilaterally at Th2 for facial hyperhidrosis/blushing (n = 49), Th2-3 for palmar hyperhidrosis (n = 62), and Th2-4 for axillary hyperhidrosis (n = 47).

RESULTS

Follow-up by questionnaire was possible in 94% of patients after a median of 26 months. Compensatory sweating occurred in 89% of patients and was so severe in 35% that they often had to change their clothes during the day. The frequency of compensatory sweating was not significantly different among the three groups, but severity was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation.

CONCLUSIONS

Compensatory and gustatory sweating were remarkably frequent side effects after thoracoscopic sympathectomy for primary hyperhidrosis. We found no significant difference between the level of sympathectomy and the occurrence of compensatory sweating. However, it appears that this is the first study to demonstrate that severe sweating is significantly more frequent after Th2-4 sympathectomy for axillary hyperhidrosis. We encourage informing patients thoroughly about these side effects before surgery.