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PubMed2000

Prognostic factors for survival in malignant melanoma of the eyelid skin.

PURPOSE: This study aimed to determine the prognostic factors for survival and disease-free interval for malignant melanoma of the eyelid skin. METHODS: This was a retrospective, nonrandomized, clinical review. Twenty-four patients with eyelid skin melanoma were identified through a search of the tumor registry at M. D. Anderson Cancer Center. Patients were treated between 1953 and 1994. The follow-up ranged from 3 to 18 years (mean = 9.6 years). Primary treatment in all cases entailed wide local excision of the tumor. Patients in whom regional lymph node metastasis developed underwent parotidectomy or neck dissection, with or without adjuvant chemotherapy or external beam radiation. Descriptive statistics were used to characterize the patients. Survival analysis in terms of disease-free survival and recurrence-free survival was performed using age, sex, location of tumor (upper lid, lower lid, or both), histologic type of melanoma, Breslow thickness, and Clark's level as independent variables for survival. RESULTS: Age, sex, location, and the histologic type of tumor were not significant prognostic indicators for survival in this cohort. Clark's level > or = IV by itself was a statistically significant predictor of decreased survival. In addition, tumors with either Clark's level > or = IV or Breslow thickness > or = 1.5 mm were associated with increased mortality. CONCLUSION: Clark's level > or = IV or Breslow thickness > or = 1.5 mm are poor prognostic indicators for malignant melanomas of the eyelid skin. Clinicians should have a high level of suspicion for occult regional lymph node metastasis when treating patients with these tumor features.

Adult↗

PubMed1998

Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Frey's syndrome).

Several therapeutic approaches exist to treat gustatory sweating (Frey's syndrome) following parotidectomy. Because of the lack of effective treatment, a new therapeutic modality using botulinum toxin injections was presented previously by our group. The duration of the demonstrated positive effect was essentially unknown so far. Based on our experiences using this technique since December 1993, the purpose of this clinical investigation was to make an up-to-date report and demonstrate the duration of effect of BOTOX injections in patients with severe gustatory sweating. Nineteen patients with severe gustatory sweating have been treated with BOTOX by intracutaneous injections into the affected skin areas. The maximal follow-up time was 33 months. The results were obtained by interviews and controls using Minor's starch iodine test. In all treated cases (n = 19 patients, 22 treated sides) gustatory sweating ceased completely within 2 days. Side effects were absent. In 12 patients gustatory sweating reappeared. The mean duration of effect was 17.3 months (subjective personal communication of 18 patients). Findings show that intracutaneous injection of BOTOX is a highly effective, safe, and minimally invasive treatment of Frey's syndrome with long-lasting therapeutic effect.

Adolescent↗

PubMed2001

Specificity of parotid sialendoscopy.

OBJECTIVE: To present our initial experience with sialendoscopy of the parotid duct. STUDY DESIGN METHODS: Diagnostic and interventional sialendoscopy procedures were performed in 79 and 55 cases, respectively. Diagnostic sialendoscopy was used to classify ductal lesions into sialolithiasis, stenosis, sialodochitis, and polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolithiasis fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms. RESULTS: Diagnostic sialendoscopy was possible in all cases, with an average duration of 26+/-14 minutes and no complications. Interventional sialendoscopy was successful in 85% of cases, with an average duration of 73+/-43 minutes (+/- standard deviation). Multiple procedures were performed in 45% of cases, general anesthesia was used in 24%, and parotidectomy in 2%. Multiple sialoliths were found in 58% of ducts and associated with more procedures under general anesthesia and longer operations. The average size of sialoliths was 3.2+/-1.3 mm; larger stones were associated with more procedures under general anesthesia, longer and multiple procedures, use of fragmentation, and sialendoscopy failures. Sialolithiasis fragmentation was required in 10% of cases, with a success rate of 70%. Semirigid sialendoscopes performed better than flexible ones. Complications were mostly minor but were encountered in 12% of cases. CONCLUSIONS: Diagnostic sialendoscopy is a new technique for evaluating salivary duct disease, a technique which is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, preventing open gland excision.

Adolescent↗

PubMed2001

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.

Animals↗

PubMed2001

Preoperative computed tomography scans for parotid tumor evaluation.

OBJECTIVE: We sought to determine whether an advantage is obtained in the routine use of computed tomography (CT) scans in preoperative assessments of parotid tumors. METHODS: A prospective study of 32 consecutive cases of patients who underwent evaluation for parotidectomies was performed. Twenty-nine received preoperative CT scans. The scans were systematically reviewed to see if they correlated with the clinical findings. Specifically, we compared clinical and CT assessments of tumor size, location, density, and malignancy. Further comparisons were performed based on postoperative tissue pathology. RESULTS: In our series of patients, routine preoperative CT scans resulted in the discovery of details not revealed on clinical examination: some masses were found to be extra-parotid rather than primary parotid tumors, some tumors deemed to be deep were superficial, tumor density was more clearly identified, and certain pathology correlates were clarified. Most importantly, there were instances of detection of additional tumors in the same lobe, and in one instance in the opposite lobe, that were not otherwise noticed. CONCLUSIONS: To reduce errors of omission in the treatment of suspected parotid tumors, it would seem appropriate to consider the inclusion of CT scans for the routine preoperative evaluation of all parotid masses.

Biopsy, Needle↗

PubMed2001

A hearing preservation technique for the resection of extensive jugular foramen tumors.

OBJECTIVE: To describe a modified surgical approach for patients who maintain hearing function with jugular foramen tumors that extend to the posterior cranial fossa and the neck. STUDY DESIGN: A retrospective review of 6 patients with jugular foramen tumors that were resected by a combined suboccipital and infralabyrinthine-transcervicomastoid approach. METHODS: A combined suboccipital and infralabyrinthine-transcervicomastoid approach is characterized as follows: 1) There is no ablation of ear structures except the infralabyrinthine mastoid bone; the auricle is retracted anteriorly while preserving the bony wall and skin of the ear canal. 2) After superficial parotidectomy, a limited length of nerve VII from the intratemporal vertical segment is rerouted to divisions of the parotid portion. 3) The tumor is removed along with the internal jugular vein and sigmoid sinus, then the extended intracranial mass is resected through an additional suboccipital approach. RESULTS: Five of the 6 patients had complete removal of all gross tumors. There were no major complications or mortalities. The preoperative levels of hearing were preserved in 5 of the 6 patients. Favorable facial function in the immediate postoperative period was noted in 4 of the 6 patients. Incomplete paralysis of 2 patients recovered eventually. CONCLUSION: We propose that a combined suboccipital and infralabyrinthine-transcervicomastoid approach to the jugular foramen can provide sufficient exposure to resect most dumbbell-shaped tumors, and it could be the initial treatment of choice for patients with remnant hearing.

Adult↗

PubMed2001

Histopathology of pleomorphic adenoma in the parotid gland: a prospective unselected series of 100 cases.

OBJECTIVES/HYPOTHESIS: Histopathological characteristics of pleomorphic adenomas, especially of capsular alterations such as thin capsule areas, capsule-free regions, capsule penetration, satellite nodules, and pseudopodia in the different subtypes, are described. STUDY DESIGN: Prospective unselected series of 100 consecutive cases from 1997 to 2000. METHODS: Light microscopic examination and semiquantitative analysis of the pleomorphic adenomas. RESULTS: Fifty-one (51%) pleomorphic adenomas were classified as myxoid (stroma-rich) type, 35 (35%) specimens as cellular type, and 14 (14%) as classic subtype. Ninety-seven percent of all tumors showed areas with thin (<20 microm) capsule independent of the tumor subtype. Tumors of myxoid subtype showed the absolute greatest regions of a thin capsule. Especially, tumors of myxoid type (71%) often had a distinct focal absence of encapsulation with tumor merging into normal parotid gland tissue; 11% of the cellular subtype and 43% of the classic subtype presented capsule-free areas. Thirty-three percent of the myxoid pleomorphic adenomas, 23% of the cellular subtype, and 21% of the classic subtype had satellite nodules or pseudopodia. CONCLUSIONS: Almost all pleomorphic adenomas have focally thin capsules. One-fourth of all pleomorphic adenomas contain abnormalities such as satellite nodules or pseudopodia. More than two-thirds of pleomorphic adenomas of the myxoid (stroma-rich) subtype and at least half of all tumors show a focal absence of the capsule. Therefore, enucleation or local dissection of the pleomorphic adenoma is not a sufficient surgical treatment of this special tumor entity. We recommend, depending on the location of the tumor, a lateral or total parotidectomy as the treatment of choice.

Adenoma, Pleomorphic↗

PubMed2002

Quality of life after parotid and temporal bone surgery for cancer.

OBJECTIVES: The purposes of this study were to examine the quality of life (QL) of patients who received treatment for cancer of the parotid or temporal region, and to identify factors contributing to it. The relationships between clinician-based measures of treatment outcome and the patient-based counterparts were also evaluated. METHODS: A retrospective, cross-sectional study was conducted on 23 patients who had received either a temporal bone resection or a combination of parotidectomy and radiotherapy. The QL survey involved both global QL and measures of the appearance, communication, hearing, physical, psychological, and social domains. Patients were assessed clinically for their performance status, facial nerve function, disfigurement, and hearing and the results were compared with patient-rated QL. Correlation between the QL variables and global QL was identified using Spearman correlation tests. RESULTS: Ongoing physical symptoms, communication difficulties, and social disturbances were associated with poorer global QL (P <.05). No correlation was detected between global QL and objective disfigurement, facial function, and measures of hearing loss. With the exception of hearing testing, clinical assessments generally did not correlate well with patient ratings. CONCLUSION: QL measures provide insight into patients' perceptions of the treatment outcome but do not necessarily correlate with the clinicians' views. The use of a global QL measure overcomes the difficulty of extrapolating the impact of symptom scores or observational measures on patients' overall quality of survival.

Activities of Daily Living↗

PubMed2002

Bilateral squamous cell carcinoma of the external auditory canals.

OBJECTIVES: To report a case of bilateral squamous cell carcinoma of the external auditory canals and to present a management algorithm for this difficult clinical scenario. STUDY DESIGN: Case report and literature review. METHODS: The study comprises a case report of a 69-year-old man who initially presented with complaints of bilateral otorrhea, left-sided otalgia, and a left-sided hearing loss. Following attempted treatment of a presumed case of otitis externa, biopsy of both external auditory canals revealed squamous cell carcinoma. A computed tomography scan demonstrated marked abnormal soft tissue in the left external auditory canal with no bony erosion and thickening of the soft tissue in the right external auditory canal. RESULTS: The left-sided lesion required a lateral temporal bone resection, a partial superficial and deep-lobe parotidectomy, and postoperative irradiation. The right-sided lesion was more limited and was managed with a lateral temporal bone resection and tympanoplasty for hearing preservation. CONCLUSIONS: Bilateral squamous cell carcinoma of the external auditory canals is an extremely uncommon but aggressive malignancy that may present with symptoms similar to a case of otitis externa, and this can result in delays in proper diagnosis. Early recognition is essential because management and prognosis are determined by the extent of the lesion.

Aged↗

PubMed2002

External auditory canal stenosis after radiation therapy.

OBJECTIVES: To determine whether the risk of external auditory canal stenosis from external-beam radiation therapy is dose dependent. STUDY DESIGN: Retrospective chart review. METHODS: The presence of external auditory canal disease was recorded for patients who received low-dose (e.g., lymphoma [20-40 Gy]), medium-dose (e.g., chemodectoma [40-55 Gy]), or high-dose (e.g., parotid and nasopharyngeal neoplasms [55-75 Gy]) external-beam radiation therapy from 6 months to over 8 years following treatment. The incidence of external auditory canal disease was compared between groups. RESULTS: None of 13 low-dose, none of 19 medium-dose, and 8 of 91 (8.7%) high-dose external-beam radiation therapy subjects developed ipsilateral external auditory canal stenosis. No external auditory canal stenosis developed in patients treated with high-dose external-beam radiation therapy in the absence of parotid surgery. External auditory canal stenosis developed only in patients treated with parotidectomy and high-dose external-beam radiation therapy (P =.0059), and all of these cases of external auditory canal stenosis developed within 3 years of radiation therapy. CONCLUSIONS: High dose external-beam radiation therapy alone does not significantly predispose patients to external auditory canal stenosis. However, combined high-dose external-beam radiation therapy and surgery around the external auditory canal do significantly increase the risk of external auditory canal stenosis.

Constriction, Pathologic↗

PubMed2003

Surgical robotic applications in otolaryngology.

OBJECTIVES: To explore the feasibility of performing endo-robotic neck surgery in a porcine model and to compare the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique. STUDY DESIGN: Prospective, nonrandomized experimental investigation in a porcine model. METHODS: We performed a consecutive series of endoscopic neck surgeries using the daVinci surgical system (Intuitive Surgical Inc.). The length of time required to establish the operative pocket and to assemble the robotic components, as well as the total duration of each operation, was recorded. The animals were continuously monitored for heart rate, blood pressure, and end-tidal CO(2) pressure, and evaluation for presence of pneumothorax and subcutaneous emphysema was undertaken postoperatively. The specimens were examined histologically. RESULTS: Four different types of neck surgery were successfully performed on both sides of the neck of four animals using the daVinci surgical system. Creation of the operative pocket took, on average (+/-SD), 18.1 +/- 11.9 minutes, and assembly of the robot required 12.5 +/- 9.9 minutes, resulting in a mean preparation time for all procedures of 30.6 +/- 21.0 minutes. The mean operative time for submandibular resection (n = 3) was 19.0 +/- 6.6 minutes, with a total procedure time of 39.0 +/- 10.2 minutes. Selective neck dissections (n = 3) required a mean operative time of 66.0 +/- 18.5 minutes and a total procedure time of 85.7 +/- 16.7 minutes. One partial parotidectomy and one thymectomy were also performed. The median estimated blood loss was 0 mL (range, 0-10 mL). The end-tidal CO(2) pressure fell from the start to the end of the procedures by a mean of 4.4 +/- 7.9 mm Hg. The blood pressure fell by a mean of 1.9 +/- 7.5 mm Hg. There was one case of modest subcutaneous emphysema, and there were no cases of pneumothorax or air embolism. No conversions to open resection were necessary. CONCLUSIONS: Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.

Animals↗

PubMed2004

Nontuberculous mycobacteria-induced parotid lymphadenitis successfully limited with clarithromycin and rifabutin.

OBJECTIVES/HYPOTHESIS: Nontuberculous mycobacterial adenitis of the parotid gland is often difficult to diagnose. The rarity of these infections in the parotid region and the lack of specific guidelines pose a treatment challenge to the clinician. Three cases of nontuberculous mycobacterial adenitis are presented, with clinical response to antibiotics before surgery. STUDY DESIGN: Retrospective chart review was made of children up to 18 years of age presenting with a parotid mass diagnosed as nontuberculous mycobacterial infection. METHODS: Three patients (age range, 15 to 30 mo) with nontuberculous mycobacteria-induced parotid lymphadenitis were treated with a combination antibiotic regimen of clarithromycin and rifabutin or with clarithromycin alone. RESULTS: All three patients responded clinically to the antibiotic treatment as evidenced by a smaller mass size and resolution of the overlying discoloration. Subsequent parotidectomy or biopsy appeared to be easier to perform because of decreased inflammation and edema and a more readily dissectible facial nerve. CONCLUSION: Children with nontuberculous mycobacteria-induced parotid lymphadenitis should be started on a trial of antibiotic treatment before surgery. Although surgery remains the definitive treatment modality, a larger study of preoperative antibiotic use against nontuberculous mycobacterial adenitis of the parotid in children is necessary.

Anti-Bacterial Agents↗

PubMed1978

Cystic lesions of the parotid gland.

In a series of 708 parotidectomies (partial or total), we found 23 cystic lesions. Of these, 16 met the criteria for so-called "branchial cysts"; five were retention cysts of duct origin, and the remaining two were epidermal inclusion cysts. The principles of diagnosis and treatment of parotid cysts are presented.

Adenolymphoma↗

PubMed1979

Cysts, masses, and tumors of the accessory parotid gland.

An accessory parotid gland occurs in approximately 21 percent of human subjects. It is located anterior to the main parotid gland, usually just above Stensen's duct and connected by its own duct to the latter. Any lesions that can occur in the main parotid gland can also arise in an accessory parotid gland. For the excision of lesions of the accessory parotid gland, we prefer to turn the same cervicofacial flap used for a lateral or total parotidectomy. This permits one to fully visualize the superficial and deep main parotid segments, the trunk and the branches of the facial nerve, and the accessory parotid gland along with its duct system and Stensen's duct.

Adenoma↗

PubMed1983

Rare synchronous parotid tumors of different histologic types.

A review of the approximately 2000 parotid salivary gland tumors studied at the Columbia-Presbyterian Medical Center in New York from 1918 to 1978 showed that separate, synchronous neoplasms of different histologic types were found in the parotid gland in only 7 patients. In 6 of these patients, there was a clinically solitary mass; in the other patient, two separate nodules were palpated. In each case, subtotal or total parotidectomy was performed. On examination of the resected tissue, two separate nodules were identified grossly in three patients; in one, a benign mixed tumor and a mucoepidermoid carcinoma; in the second, a benign mixed tumor and a Warthin's tumor; and in the third, a mucoepidermoid carcinoma and a Warthin's tumor. In the remaining 4 patients, only one grossly evident tumor was found, including benign mixed tumor in 3 patients and a poorly differentiated adenocarcinoma in 1 patient. In each of these cases, the second tumor, discovered only microscopically, was a Warthin's tumor. Thus, in 6 of the 7 patients, the second neoplasm was a Warthin's tumor.

Adenolymphoma↗

PubMed1986

Aneurysm of the superficial temporal artery presenting as a parotid mass.

True aneurysms of the superficial temporal artery are rare and are associated with atherosclerosis. If the aneurysm occurs in the proximal portion of the superficial temporal artery, it may present as a parotid mass, encompass the facial nerve, and require superficial parotidectomy, as it did in this patient. Preoperative assessment with ultrasonography was the most useful diagnostic test because the aneurysm was thrombosed and was not visible by angiography. Thrombosed superficial temporal artery aneurysm should be in the differential diagnosis of parotid masses.

Aged↗

PubMed1986

Pilomatrixoma presenting as a parotid mass.

A rare case of calcifying epithelioma of Malherbe presenting as a large parotid mass is reported in this paper. Preoperative evaluation and considerations are discussed. An exact diagnosis and definitive treatment in this patient consisted of superficial parotidectomy and histologic study.

Adolescent↗

PubMed1994

Gustatory rhinorrhea--a complication of septoplasty.

A previously unreported complication of septoplasty, which is the profuse flow of thin clear nasal drainage on mastication, is described. Of a combined group of 1332 patients with septoplasty and septorhinoplasty, 6 females and 1 male presented with gustatory rhinorrhea after surgery. The average age of the patients who experienced this complication was 44.43 years. Three patients tested the efficacy of antihistamines, which proved helpful in reducing the severity of this condition. The cause of gustatory rhinorrhea is postulated as inadvertent injury to the nasopalatine nerve within the septal layers after removal of the deviated portion of the vomer and the perpendicular plate of the ethmoid bone during septoplasty. It is the authors' supposition that regenerating nerve sprouts are inappropriately directed toward nasal, rather than palatal, target receptors. Consequently, rhinorrhea results while eating. The pathophysiology of this new finding is not dissimilar to gustatory sweating after parotidectomy. Although this complication is not life-threatening, it is socially disturbing to patients. The authors believe that awareness of this sequela will lead to the discovery of a larger patient population and a potential treatment or prevention.

Adult↗