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PubMedDate not supplied

Adenocarcinoma of the parotid.

All of the consultants considered needle biopsy an integral tool in management of a parotid neoplasm. If the tumor was limited to the superficial lobe of the parotid, they were split between ordering no further tests (Drs. Johnson and Glenn) and proceeding with a CT scan (Dr. Beckford). If frozen section revealed adenocarcinoma, the consultants agreed that a total parotidectomy with preservation of any uninvolved nerve would be in order. If the nerve had to be sacrificed, repair should be with a greater auricular or sural nerve graft. Two consultants (Drs. Beckford and Glenn) would search for a distant primary or metastasis. Controversy regarding management of an N0 neck divided the group into favoring neck dissection (Drs. Beckford and Johnson) and a modified radical neck dissection (Dr. Glenn). In the case of anaplastic carcinoma the consultants differed by suggesting an extended resection (Dr. Beckford), total parotidectomy with nerve preservation (Dr. Johnson), and total parotidectomy with modified radical neck dissection (Dr. Glenn). All the consultants recommended postoperative radiotherapy.

Adenocarcinoma↗

PubMedDate not supplied

Recurrent pleomorphic adenomas of the parotid gland.

Twenty-seven patients with recurrent pleomorphic adenomas of the parotid gland were seen. This study confirms that superficial parotidectomy with identification and dissection of the facial nerve greatly decreases the incidence of recurrent benign pleomorphic adenoma, and, in the small number that recur, are easier to cure. All lumps in the parotid area should be approached in the same manner, with the surgeon prepared to isolate the facial nerve and perform superficial parotidectomy. This technique is successful because it avoids dissection near the tumor capsule, which is the major cause of recurrence. The procedure recommended for treatment of patients to remove the first recurrent tumor is total parotidectomy and excision of the previous scar. This vigorous approach is dictated by the increasing difficulty of removing further recurrent tumors. Only 67% of patients with recurrent tumors ultimately achieve a tumor-free status. Experienced surgeons can preserve the facial nerve even after multiple operations.

Adenoma↗

PubMedDate not supplied

Surgical management of chronic parotitis.

A series of 17 consecutive parotidectomies for chronic sialoadenitis is presented. This comprises 10% of all parotidectomies performed by one surgeon over the 5-year period between 1987 and 1991. In 16 patients, symptoms were relieved by surgery. The extent of surgery was guided by the clinical findings. In this series, near total and superficial parotidectomy were equally efficacious and no patient suffered permanent facial nerve dysfunction. Surgery is a safe and effective treatment for parotitis.

Adult↗

PubMed1999

Parotid region lymphatic mapping and sentinel lymphadenectomy for cutaneous melanoma.

BACKGROUND: Routine elective superficial parotidectomy for patients with primary cutaneous melanomas of the scalp, auricle, or face has been questioned. We evaluated an alternative, i.e., lymphatic mapping and sentinel lymphadenectomy, for patients with primary cutaneous melanomas draining to the region of the parotid gland. PATIENTS: Retrospective review of our large (>8000 patients) melanoma database identified 39 patients with primary melanomas (American Joint Committee on Cancer stage I or II) of the scalp (n = 19), auricle (n = 11), or face (n = 9) who underwent intraoperative lymphatic mapping to identify a sentinel node (SN) in the region of the parotid gland, between June 1985 and July 1997. RESULTS: A SN was identified in the parotid region of 37 patients (94.9%), four of whom had SN metastases. The mean number of SN obtained was 2.3/patient (range, 1-4/patient). The two patients (5.1%) for whom a parotid-region SN could not be identified underwent superficial parotidectomy during the same operation. Among the 33 patients with tumor-free SN, with a median follow-up period of 33.2 months (range, 1-121 months), there was one (3.1%) intraparotid recurrence; thus, the false-negative rate was 3.1%. The procedure-related surgical morbidity rate was only 2.6% (one case of temporary facial nerve paresis). CONCLUSIONS: For patients with primary melanomas of the scalp, auricle, or face, sentinel lymphadenectomy can be performed accurately in the parotid region and offers a low-morbidity alternative to routine elective superficial parotidectomy.

Adult↗

PubMedDate not supplied

Neck masses secondary to heterotopic salivary gland tissue: a 25-year experience.

OBJECTIVES: The aim of this study is to review salivary tumors arising from heterotopic salivary inclusions in the periparotid and cervical lymph nodal tissues over a 25-year span. METHODS: A retrospective chart review revealed 24 patients with asymptomatic neck masses treated between 1976 and 2001, whose pathology demonstrated heterotopic salivary tissue or neoplasms arising from heterotopic salivary tissue. RESULTS: Nine cases were benign periparotid lymph nodes with heterotopic salivary inclusions, 3 of which had multimodal involvement. Fifteen cases of heterotopic salivary tumors were identified. The benign tumors were predominantly Warthin's tumor (8) with 1 pleomorphic adenoma. Malignant tumors included mucoepidermoid (3), acinic cell (2), and adenocarcinoma (1). Patients were treated by a superficial parotidectomy, neck dissection, or simple excision depending on site and preoperative workup. Adjuvant radiation therapy was included for high-grade malignancies. Among the 15 tumor patients, follow-up ranged from 1 month to 17 years. Nine patients are alive and disease-free, 5 are deceased, and 1 was lost to follow-up. CONCLUSIONS: Heterotopic salivary tissue in periparotid and upper cervical nodes is a more common occurrence than historically recognized. Tumorigenic changes arise from heterotopic nodal inclusions, and although infrequent, should be considered in the differential diagnosis for isolated neck/periparotid masses and parotid Warthin's tumor. Suggested management, after a thorough clinical exam/needle aspiration biopsy, includes an imaging survey of the parotid gland and neck lymphatics with an appropriate resection to include a simple excision, parotidectomy, neck dissection, and/or irradiation as indicated. Isolated low-grade malignant lesions/benign lesions are adequately managed by excision or parotidectomy alone. High-grade malignant lesions require more extended surgery with possible irradiation.

Adenocarcinoma↗

PubMed2004

Preoperative distinction of parotid lymphomas.

BACKGROUND: Surgical parotidectomies place parotid lymphoma patients at increased risk of morbidity because of the diffuse infiltrative nature of the disease. These tumors usually respond to radiotherapy or chemotherapy, but are difficult to distinguish from other benign parotid gland tumors preoperatively. We sought to identify clinical and radiologic features that could aid in the preoperative distinction of parotid lymphomas. STUDY DESIGN: We performed a retrospective chart review of 248 superficial parotidectomy patients. RESULTS: Of 248 parotid lesions, 22 (8.8%) were lymphomas (21 non-Hodgkin's, 1 Hodgkin's). The lymphoma cases included four patients with a history of autoimmune disease, and four with a previous diagnosis of lymphoma. Palpable painless masses were present in all cases (14 right, 7 left, 1 bilateral). Two patients had multiple palpable parotid nodules and five had palpable cervical adenopathy. Of 17 patients receiving preoperative CT scans, 4 more patients were revealed to have bilateral disease, 7 more patients had cervical adenopathy, and 5 more patients had multiple parotid nodules. Tumors were poorly circumscribed in 7 of 17 (41%), and diffuse parotid changes were noted in 2. Preoperative fine needle aspiration biopsy was performed in 10 of the 22 lymphomas, revealing 3 reactive nodes, 3 suspicious for lymphoma and 3 nondiagnostic. CONCLUSIONS: Although parotid lymphomas are uncommon, a history of autoimmune disease or previous lymphoma; clinical or radiologic evidence of bilateral, multiple, or poorly circumscribed parotid lesions; and cervical lymphadenopathy should suggest this diagnosis. This may alter the proposed surgery and decrease the potential morbidity associated with superficial parotidectomy in cases of parotid lymphoma.

Adult↗

PubMed2004

Frey syndrome. A proposal for evaluating severity.

We aimed to establish the incidence of Frey's syndrome in patients that have been submitted to partial and total parotidectomy at a cancer-treating hospital in Mexico City and to propose a grading system to determine its severity. The incidence of Frey's syndrome in 77 patients (25 male and 52 female) under oncological follow-up due to parotid tumors was subjectively evaluated through clinical findings and objectively diagnosed through Minor's test. The positive hyperhydrotic areas were recorded and measured on transparent acetates. Numeric values were assigned according to clinical perception of symptomatology by the patients (0 for no perception and 1 for clinical recognition), extent of the affected area (1 if less than 2 cm; 2 if between 2.1 and 4 cm, and 3 if more than 4 cm), intensity and smell of sweat (3 if it was excessive or of unpleasant odor). Results were expressed as mild (if less than 4 points) or severe grades (if 4 or more points). Frey syndrome was objectively diagnosed in 28 patients (36%), although only 17 (22%) recognized to have clinical manifestations of this condition. There were 22 women (79%) and six men (21%). Of these, seventeen (61%) had been subjected to partial and eleven (39%) to total parotidectomy. Adjuvant radiotherapy had been employed in nine cases (32%). The cutaneous affected area in the whole group ranged from 0.7 to 29.8 cm(2) (mean 8.9 cm(2)), with a mean affected surface of 8.7+/-10.8 cm(2) for women and 9.0+/-8.8 cm(2) for men ( p > 0.05). Twelve cases were classified as mild and sixteen as severe. No significant differences were found between patients treated with partial vs. total parotidectomy or between patients treated with or without adjuvant radiotherapy. The incidence of Frey's syndrome in Mexican patients seems to be similar to those reported in other countries; however, the extent of hyperhydrosis is lower when compared to some European studies. Our proposal for evaluating this condition may be a helpful tool in assessing the incidence and severity among the diverse populations and it may be a useful tool to define more precisely the indications for treatment and to evaluate the available therapeutic methods according to the severity of the condition.

Adolescent↗

PubMed1998

Facial nerve monitoring in parotid surgery: the standard of care?

Recent reports have suggested that the incidence of permanent facial nerve paralysis or paresis after surgery for benign parotid tumors is between 3% and 5%. The intraoperative use of nerve-integrity monitors has been advocated to reduce the incidence of facial nerve paralysis. The purpose of this study was to compare postoperative facial nerve function after monitored and unmonitored parotid surgical procedures. The charts of 69 consecutive patients with parotid lesions who underwent surgery from 1987 to 1996 were retrospectively surveyed. Sixteen high-risk patients were excluded from the study. The study group consisted of 53 patients (33 unmonitored and 20 monitored) who underwent lateral parotidectomy for mobile tumors of the superficial lobe of the parotid gland. No patient demonstrated permanent facial paralysis. In 9 patients (17%), transient nerve paralysis developed: 5 (15%) of the 33 patients who underwent lateral parotidectomy without the use of a nerve-integrity monitor and 4 (20%) of the 20 patients who underwent lateral parotidectomy with the use of a nerve-integrity monitor. Nerve-integrity monitoring is optional for mobile parotid tumors of the superficial lobe.

Facial Nerve↗

PubMedDate not supplied

Metastasis to the parotid gland: is a radical surgical approach justified?

INTRODUCTION: At the time of this writing, it is unclear whether metastasis to the parotid gland necessitates a radical surgical approach, including removal of the facial nerve, which results in a great loss of the patient's quality of life. MATERIALS AND METHODS: The clinical course of patients who underwent parotid surgery in the ENT clinic of Hamburg University during the period 1982-1992 as a result of metastasis of a malignant melanoma or squamous cell carcinoma was studied. Either the lateral portion of the gland was removed (laterofacial parotidectomy) or the whole gland, thereby preserving the facial nerve (total parotidectomy) or removing it (radical parotidectomy). RESULTS: Metastasis to the parotid gland occurred in 17 patients (17/347). All 10 patients with metastasis of a malignant melanoma developed further metastasis and 7 of these patients, independent of the radicality of parotid surgery, died within the first postoperative year. Of the 7 patients with metastasis of a squamous cell carcinoma, 5 developed further metastasis and 4, independent of the radicality of parotid surgery, died within 16 months after the operation. CONCLUSION: Radical parotid surgery, which involves a great loss of quality of life for the patient, does not positively influence life expectancy. Moreover, the long-term prognosis is influenced by the type of the tumor and the stage at which the disease is first diagnosed.

Carcinoma↗

PubMed2003

Oncocytic mucoepidermoid carcinoma of parotid gland origin.

This article reports 3 cases of oncocytic mucoepidermoid carcinoma of the parotid gland and compares them with 9 cases from the literature with emphasis on clinical behavior, treatment, and recurrence rate. The tumor occurs most often in the middle-aged to elderly, with a decided predilection for the parotid gland. All three oncocytic mucoepidermoid carcinomas from the Armed Forces Institute of Pathology series were low grade with extensive oncocytic change. Treatment modalities consisted of superficial parotidectomy, total parotidectomy, or total parotidectomy. The mean follow-up interval was 5.5 years. Only one case from the literature, a high-grade mucoepidermoid carcinoma, recurred. Results of this study indicate that the parotid gland oncocytic mucoepidermoid carcinoma behaves in a fashion similar to typical mucoepidermoid carcinoma, with prognosis dependent on clinical stage, histopathologic grade, and adequacy of treatment. Recognizing the spectrum of oncocytic differentiation in salivary gland tumors will serve to establish appropriate diagnoses and treatment.

Aged↗

PubMed1990

Benign parotid tumour enucleation--a reliable operation in selected cases.

The method of surgical treatment for benign tumours of the parotid gland had not yet been rationalized, but many authors recommend parotidectomy as the most appropriate procedure. A series of 289 operations for parotid swelling is reported; the majority of mixed and Warthin's tumours underwent enucleation without either complications or recurrence. The rationale of parotidectomy versus enucleation is discussed but in fast growing, deeply infiltrating and recurrent tumours, parotidectomy appears to be the best choice. In the other group of more commonly occurring tumours, enucleation represents a reliable time saving option.

Adenolymphoma↗

PubMed2001

Pleomorphic adenomas of the major salivary glands: a study of the capsular form in relation to surgical management.

This was a retrospective study of 126 primary pleomorphic adenomas to correlate capsular characteristics with tumour histopathology in relation to current surgical debate (parotidectomy versus local excision). Capsular thickness was measured by micrometry and tumours classified into subtypes (1-4). Evidence of fine needle aspiration damage (needle tracks, infarction) was sought. Minimal changes were seen in eight tumours. Tumour growth features (bosselations, enveloping) were present in 57% and 33%, respectively, also microinvasion (42%) and tumour 'buds' (12%). Parotid lesions possessed thicker capsules than submandibular tumours. There was little correlation between capsular thickness and cellular structure. The significant exception was large (> 25 mm) hypocellular parotid tumours which had thinner capsules and could be vulnerable to operative rupture. In 110 standard operations (parotidectomy, submandibular gland excision), capsular exposure was evident in 81%. Field irrigation is recommended to lessen the risk of tumour seeding. This study reaffirms many elements of capsular weakness and suggests that parotidectomy is the operation of choice.

Adenoma, Pleomorphic↗

PubMed2001

Surface landmarks of the facial nerve trunk: a prospective measurement study.

BACKGROUND: Facial nerve identification and preservation is the key to safe parotidectomy in most clinical situations. Traditional approaches to the main trunk have depended solely on internal landmarks but localization may further be enhanced if data are available on its position with reference to neighbouring external features. METHODS: Prospective measurements were taken on a series of parotidectomy patients intraoperatively. Using that spot on the main trunk 10 mm proximal to its bifurcation as the reference point, the depth from the skin and its cranio-caudal distance from the summit of the tragus were measured. RESULTS: Thirty-three patients were included, whose body mass index showed that they had average body build. The reference point nerve was 23.6 mm (SD = 5.1 mm) from the skin surface, and 18.8 mm (SD = 6.0 mm) caudal to the tragus. CONCLUSION: Measurements relating to the siting of the facial nerve trunk were obtained live at operation. This information should be helpful in the initial mobilization of the parotid gland from its posterior relations and in facilitating the classical internal landmarks in the 3-D localization of the main trunk, thereby allowing quicker and safer parotidectomy.

Adult↗

PubMed2003

Parotid neoplasms in children: experience of diagnosis and management in a district general hospital.

Parotid neoplasms are uncommon in children and the available literature is predominantly from specialized centres. This paper highlights our experience at a district general hospital, in the diagnosis and management of parotid neoplasms in children. The case records of all parotidectomies performed in a 26-year period between 1974-1999 were scrutinized and patients aged 18 years and below identified. The demographic data, histology, presentation, investigations, treatment, outcomes and complications were analysed. 545 parotidectomies were performed in 536 patients, in whom 569 neoplasms were diagnosed. Only 12 patients aged 18 and under were identified (2.2%). The relative frequency of individual tumours differed markedly from that in adults. 75% of the tumours were benign. Pleomorphic adenoma and mucoepidermoid carcinoma were the most common tumours. A painless mass was the most frequent clinical presentation and CT sialogram was the most common investigation. Parotidectomy with preservation of the facial nerve was performed in all cases, and adjuvant radiotherapy employed in the case of malignant tumours. All patients were alive and well at the time of last follow up. Transient facial nerve palsy and hypertrophic scars were the most common complications.

Adenoma, Pleomorphic↗

PubMed2003

Parotid surgery using Nd:YAG laser contact tips: clinical assessment of perioperative facial nerve function.

OBJECTIVE: The objective of this paper is to review 51 consecutive contact Nd:YAG laser parotidectomies to determine perioperative outcomes and complications related to the facial nerve and the use of the laser tips. BACKGROUND DATA: Parotid surgery is mostly performed with scalpel or scissors, techniques that may put the facial nerve at risk for injury due to brisk bleeding and imprecise dissection. Even though previous experiences with Nd:YAG lasers in surgery had raised concerns of energy dispersion, the contact sapphire tips used in this series allowed accurate precise dissection and hemostasis, limiting complications. MATERIALS AND METHODS: Close facial nerve dissection was done at 8-12 watts, for an average total of 8,000-12,000 joules per case. RESULTS: No significant or permanent facial nerve complications resulted from the use of the laser tips, except for expected transient and reversible postoperative ipsilateral marginal mandibular nerve paresis observed in 43% of the patients-less than the generally quoted 50% expected after uneventful lateral lobe parotidectomy. CONCLUSION: This review concludes that the contact Nd:YAG laser may offer significant technical and safety advantages, and no direct associated complications in the dissection and preservation of the facial nerve in parotidectomy.

Aged↗

PubMed1995

Frey's syndrome: prevention with temporoparietal fascial flap interposition.

The recent trend in management of Frey's syndrome has been the use of prophylactic procedures performed at the time of parotidectomy to prevent its symptoms postoperatively. An additional benefit of this approach is the prevention of the typical cheek contour deformity after parotidectomy. We reviewed our experience with interposition of a vascularized temporoparietal fascial flap between the parotid bed and overlying skin immediately after complete superficial parotidectomies to prevent Frey's syndrome and contour defects. The results of seven consecutive attempts revealed it to be an effective technique, achieving both goals in all patients with minimal morbidity.

Adult↗

PubMed2000

Prophylaxis against Frey's syndrome in parotid surgery.

In 1990 the authors reported their preliminary study of the prevention of Frey's syndrome in 55 patients utilizing a superficial musculoaponeurotic system (SMAS) flap in parotid gland surgery. During the past 10 years, numerous studies have supported their original thesis that interposition of living tissue between the resected gland bed and the skin could prevent the development of this complication. The authors have expanded their own patient population and now consider this a definitive study on the prevention of Frey's syndrome. A total of 160 patients are presented with a follow-up period of 5 to 22 years. All patients underwent subtotal or total parotidectomy performed by one of the authors. A history was acquired and testing for Frey's syndrome (Minor's starch iodine test) was performed. As a result of this approach, and in spite of the intensive search for it, no cases of Frey's syndrome were encountered. The hoped-for secondary benefit of preventing the postparotidectomy retromandibular depression was somewhat less satisfactory, although most patients remain satisfied with their appearance. The debilitating symptoms in Frey's syndrome, which is reported to have an incidence of 5% to 50% in the typical parotidectomy patient, can be avoided with thoughtful preoperative planning. The authors favor an aesthetic incision followed by the development of an SMAS flap. The parotidectomy is then performed using the surgeon's preferred technique. The SMAS flap is then placed into the bed of the resected parotid gland. This institutes a protective tissue barrier guarding against the aberrant anastomotic communication between the postganglionic secretomotor fibers intended for the parotid gland, and the now adjacent sweat glands. Their patient population is large enough to provide significant evidence that Frey's syndrome can be prevented, compared with a meta-analysis of parotid patients in multiple other studies in the literature. Assuming the patient's history and pathology does not preclude its use, the SMAS flap should be considered the standard of care for preventing Frey's syndrome in the postparotidectomy patient. If the SMAS flap is not available, a temporoparietal fascial flap has proved to be a good alternative.

Female↗

PubMed1999

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.

Adolescent↗