ORL 2014;76:121–126 DOI: 10.1159/000362605 Received: October 14, 2013 Accepted after revision: March 31, 2014 Published online: May 24, 2014
© 2014 S. Karger AG, Basel 0301–1569/14/0763–0121$39.50/0 www.karger.com/orl
Original Paper
Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision Junming Chen Sucheng Tang
Weixiong Chen Yuejian Wang
Jianli Zhang
Fayao He
Zhaofeng Zhu
Department of Otolaryngology, First People’s Hospital of Foshan, Foshan, PR China
Key Words Endoscope · Partial-superficial parotidectomy · Tumor Abstract Objectives: The aim of this study was to evaluate the feasibility of an endoscope-assisted partial parotidectomy through a modified retroauricular incision. Patients and Methods: Thirty patients with benign parotid superficial lobe tumors with a diameter of 2.4 ± 0.5 cm, located in the anterior portion of the inferior auricular lobule, underwent an endoscope-assisted partial-superficial parotidectomy. A retrograde approach through a small skin incision was used. An additional 30 patients who underwent conventional surgeries were used as controls. The operation time, operative bleeding volume and subjective satisfaction with the incision scar were compared between the groups. Results: All operations were successfully performed. The endoscopic surgery duration (74.8 ± 15.7 min), bleeding volume (12.7 ± 3.9 ml) and incision length (4.8 ± 0.4 cm) differed between the groups (p = 0.001). The mean patient satisfaction score was 8.6 ± 1.2 in the endoscope-assisted surgery group and 5.4 ± 1.3 in the control group (p = 0.001). There were no tumor recurrences during the 9–36 months of followup. Conclusion: Endoscope-assisted partial-superficial parotidectomy via a modified retroauricular incision is a feasible method for the treatment of benign parotid superficial lobe tumors located in the anterior portion of the inferior auricular lobule. The main advantage of this procedure was that the small operative scars improved the cosmetic results. © 2014 S. Karger AG, Basel
J.C. and W.C. contributed equally to this work. Yuejian Wang, MD, PhD Department of Otolaryngology First People’s Hospital of Foshan Foshan 528000 (PR China) E-Mail wangyuejian1997 @ 163.com
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ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Introduction
Benign parotid gland tumors account for the majority of parotid gland neoplasms [1]. The recommended treatment for small benign tumors located in the superficial parotid gland lobe is a partial-superficial parotidectomy; however, conventional parotid surgeries leave a large S- or Y-shaped scar [2]. Additionally, the large wounds and the wide operative areas associated with these procedures have created concerns for many patients, and a long incision with attendant scarring is difficult to accept for most patients [3]. Therefore, an alternative method with improved aesthetics is needed to meet the patients’ increasing cosmetic demands. Endoscopic surgery, such as endoscopic thyroidectomy, has been used frequently on the head and neck. One of the advantages of this type of surgery is that it leaves a smaller postoperative scar compared with the conventional approach [2]. In this study, we present a new endoscope-assisted partial-superficial parotidectomy approach through one small skin incision that improves the cosmetic results. Patients and Methods From February 2009 to August 2012, 30 patients with benign parotid tumors were selected to undergo an endoscope-assisted partial-superficial parotid surgery. The group consisted of 15 males and 15 females. The patients ranged in age from 30 to 65 years (mean age: 48). The control group consisted of 17 males and 13 females with a mean age of 47 years (range: 30–64) who underwent a conventional surgery. Both groups of patients were matched on age, sex and tumor volume (table 1). Their clinical symptoms and physical signs included painless tumors anterior or inferior to the auricular lobules. The tumor surfaces were smooth with clear borders. The endoscope-assisted parotid surgery method was explained to all patients and their families before the operation, and their consent was obtained. The Foshan Hospital of Yat-sen University Institutional Review Board approved this study. All patients underwent either a CT scan or MRI before the operation (fig. 1a, b). The indication for an endoscopic parotidectomy was a parotid superficial lobe neoplasm with a 30 mm maximum diameter located at the anterior or inferior portions of the auricular lobule. Patients with a suspected malignant parotid tumor, acute inflammatory stage sialadenitis, a radiotherapy history, preexisting facial paresis or a recurrent tumor were excluded. The patients were placed in the supine position with a pillow under a shoulder. Additionally, all 30 patients received general anesthesia. The operating team consisted of the chief surgeon, the endoscope assistant and a scrub nurse. A skin incision was made during the surgery. The incision went from the trailing edge of the ear lobe ditch up approximately 2.0–2.5 cm and was curved, extending approximately 2–3 cm to the mastoid. The total incision length was 4.0–5.5 cm. The incision did not exceed the hairline, and the lowest region was set above the earlobe (fig. 1c). The working space was produced by elevating the skin flap with self-designed, custom-made retractors to establish a stable operative space (fig. 2a). The tissue under the platysma was dissected using an electrotome or an ultrasonic scalpel (Ethicon Endo-Surgery, Shanghai, China) at a power level of three. The incision clearly exposed the anterior superficial lobule border of the parotid gland. The parotid tissue was then dissected away from the sternocleidomastoid. Notably, the great auricular nerve was protected under the 4-mm diameter, 0°-angle endoscope (Karl-Storz, Tuttlingen, Germany). After dissection between the skin flap and the superficial parotid gland lobe, the main facial nerve trunk was identified (fig. 2b). The major landmark for the main facial nerve trunk identification was the tympanomastoid fissure. Additionally, the peripheral facial nerve branches were dissected by dividing the glandular tissue. Due to the endoscope amplification, the facial nerve branches were clearly identified (fig. 2b). After the facial nerve exposure, the parenchymal dissection could be performed safely. The tissue specimens were sent for frozen sectioning, and the results demonstrated that all tumors were benign. As the cervical facial nerve trunk was exposed, the tumor was excised together with a normal parotid parenchyma margin of 0.5–1 cm. For the final histologic examinations, all specimens were sent for paraffin sectioning. Finally, the wound was closed with 4-0 Dexon subcuticular sutures, and a small ventricular drainage tube was placed for drainage. The conventional operation procedure was the same as previously described [4].
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ORL 2014;76:121–126 © 2014 S. Karger AG, Basel www.karger.com/orl
DOI: 10.1159/000362605
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Table 1. Comparison of endoscope-assisted and conventional surgeries
Male/female, n Age, years Pleomorphic adenoma/Warthin’s tumor, n Incision length, cm Operative bleeding volume, ml Operation time, min Tumor diameter, cm Subjective satisfaction with incision scar (VAS)
Endoscope-assisted surgery (n = 30)
Conventional surgery (n = 30)
p value
15/15 48 ± 11 19/11 4.8 ± 0.4 12.7 ± 3.9 74.8 ± 15.7 2.4 ± 0.5 8.6 ± 1.2
17/13 47 ± 12 21/9 12.2 ± 1.4 31.0 ± 8.9 103.2 ± 10.3 2.5 ± 0.4 5.4 ± 1.3
0.60 0.66 0.89 0.001* 0.001* 0.001* 0.46 0.001*
a
Color version available online
Values are represented as mean ± SD, unless otherwise specified. * p < 0.05.
c
b
a
b
c
Color version available online
Fig. 1. CT and incision. a, b In 1 patient, a solid lesion (white arrows) with a clear margin was found by a CT scan of the right accessory gland. c The concealed incision (black arrow) started from the trailing edge of the ear lobe ditch up approximately 2.0–2.5 cm and then turned downwards to the mastoid. The incision did not exceed the hairline, and the lowest level observed was above the earlobe.
Fig. 2. Tumor resection through a retroauricular incision and the subsequent scar formation following surgery. a The working space was constructed after the tissue under the platysma was undermined by a blunt and sharp dissection. It was produced by elevating the skin flap with self-designed, custom-made retractors. b The main facial nerve trunk (white arrow) was dissected and then exposed, and the main facial nerve branches (black arrows) were dissected. c The small postoperative scar was concealed in the postauricular area, resulting in an improved cosmetic result. A postoperative photograph of case 1 illustrates the pleasing aesthetic results with concealed incision scars 9 months following surgery.
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ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Statistical Analysis The outcomes of the two groups were compared in terms of operation time, operative bleeding volume and subjective satisfaction. Additionally, the incision scars were evaluated 6 months after the surgeries using a visual analog scale (VAS) that ranged from 0 to 10, with a higher score representing greater patient satisfaction [5]. The operative time was defined as the time from incision to closure. The data for each group were expressed as mean ± standard deviation (SD). Statistical comparisons between the two groups were performed with Student’s t tests using SPSS 16.0 (SPSS Inc., Chicago, Ill., USA) for Windows. p < 0.05 was regarded as statistically significant.
Results
All 30 operations were successfully performed endoscopically, and no conversions to a conventional open resection were necessary. The postoperative pathological examinations showed 11 Warthin’s tumor cases and 19 pleomorphic adenoma cases. The pathology also proved that complete tumor removal was achieved in all cases. All resection margins were free from tumor invasion within 0.5–1 cm. The operating time was 74.8 ± 15.7 min (range: 60–110), and the bleeding volume was 12.7 ± 3.9 ml (range: 10–20). The patients were discharged on the next postoperative day following drainage tube removal. Only 1 patient developed transient facial paresis after the endoscope-assisted surgery and recovered within 1 month. None of the patients developed capsular ruptures, salivary fistulas or Frey syndrome. All patients were disease-free, and the follow-ups occurred between 9 and 36 months (mean: 23). In the conventional surgery group, the operating time was 103.2 ± 10.3 min (range: 80–117) and the bleeding volume was 31.0 ± 8.9 ml (range: 20–50). Using a t test analysis, the endoscopic surgery bleeding volumes were smaller than those observed in the conventional surgeries (p = 0.001), and the operation times were shorter than those of the control group (p = 0.001). On a VAS, the mean patient satisfaction score regarding the incision scars was much higher in the endoscopeassisted group compared with the control group (p = 0.001) (table 1). There were no scar formations observed on the face and neck because of the retroauricular incisions (fig. 2c). Discussion
Conventional parotid surgery is performed using an S-shaped or Y-shaped skin incision to allow for complete tumor resection with safe facial nerve dissection; however, this surgery leaves a large scar. The long incision and wide exposure of the operative area due to these procedures frequently create discomfort for most patients. Thus, the function of many parotid and cosmetic surgery scholars has been to develop new surgical techniques. Endoscopy has been used in thyroid [6], submandibular gland [7] and branchial cleft cyst surgeries [5]. The successful application of endoscopies during neck surgery made parotid endoscopic surgery possible. Lin et al. [8] first reported 16 endoscopic-assisted parotidectomy cases using a modified ‘S’-incision, and although the incision narrowed, it was still visible. Additionally, Xie et al. [9] reported five single-incision surgery cases that were anterior to the tragus for superficial benign tumor parotidectomies. A single incision, however, was only suitable for tumors located in the tragus region and not for tumor resection under the earlobe. Sun et al. [1] used an ear plus a mandibular incision for parotid tumor resections in the superficial lobe. Li et al. [10] adopted an incision under the tragus lobe for benign tumors in the parotid superficial lobe; however, both jaw and ear incisions were visible, and two-incision surgeries increased trauma. Chen and Chang [11] used a 3.1-cm long retroauricular incision that was more subtle. These authors achieved excellent cosmetic results, but because the field of view is narrow, this approach is only suitable for benign tumors in the caudal lobe.
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ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
We used a retroauricular incision located 2.0–2.5 cm above the earlobe behind the ear that was curved and extended approximately 2–3 cm. The incision length was 4.0–5.5 cm, and the lowest point of the incision was never lower than the earlobe. The incision length was much shorter than that of the control group, and there was no scar formation on the face and neck; therefore, we achieved better cosmetic results. Because of the endoscopic technique, almost all superficial parotid gland areas were exposed, except the anterior portion. The upper part of the tragus has a low parotid tumor incidence rate [2]; thus, this approach is suitable for most benign superficial parotid gland tumors. Additionally, the surgical flap aspect ratio was small, and the flap was thicker. Moreover, the thicker flap has a smaller risk for necrosis [5]. In the present study, there were no flap necrosis or postoperative color change cases. Facial paralysis is one of the most common parotid surgery complications, and protecting the facial nerve during surgery is particularly important. With endoscopic lighting and amplification, the facial nerve trunk is easier to identify [2]. Additionally, when coupled with the ultrasonic scalpel, it was easy to occlude blood vessels, which resulted in less bleeding, an improved vision and a decreased risk of lesions on facial nerve branches in our endoscope-assisted group. There was only one postoperative temporary paralysis case of the marginal mandibular facial nerve branch in our study, and there were no permanent facial paralysis cases. Our results were consistent with the Sun et al. report [1], while this surgery also had the advantage of preserving facial nerves. Furthermore, the total operation time of our surgery was considerably shorter than that of conventional surgeries because of the harmonic scalpel use. The harmonic scalpel cuts and coagulates via ultrasonic blade vibrations at 55,000 Hz, which denatures proteins and forms a coagulum that seals the vessels. Vessels up to 5 mm in diameter can be sealed by coaptation. Thus, the operative field is clean and bloodless, and accidental injury or facial nerve branch abrasions can be avoided [12]. In our study, the bleeding volume was smaller than that of the conventional group. These results indicate that our surgery also had the advantage of reduced bleeding. In the present study, we completed benign parotid tumor resections and removed tumor margins (0.5–1 cm of normal parotid tissue) to ensure an adequate safety margin and prevent recurrence. O’Brien [4] reported 363 limited (partial) superficial benign neoplasm parotidectomies, and their recurrence rate was only 0.8% with a median postoperative period of 6 years. O’Brien [4] concluded that limited superficial parotidectomy is associated with very low morbidity and recurrence rates and that complete superficial parotidectomy is not warranted for benign localized parotid tumor treatment. In another study, Witt [13] reported that a 1-cm area of normal parotid parenchyma around a benign pleomorphic adenoma was a safe margin. The surgical treatment outcomes (capsular exposure, tumor-facial nerve interface, capsular rupture, recurrence, facial nerve dysfunction and Frey’s syndrome) of mobile, superficial parotid gland lobes smaller than 4 cm were not significantly altered by the surgical approach (total-superficial parotidectomy, partial-superficial parotidectomy or extracapsular dissection). Therefore, partial parotidectomy is an adequate treatment for pleomorphic parotid gland adenomas. In the present study, the surgical margin was 0.5–1 cm, and there was no recurrence during the follow-up. These results are consistent with those of Sun et al. [1] and Huang et al. [2], indicating that the surgery caused a low recurrence rate. Conclusion
Improved endoscopic-assisted surgery using a small incision behind the ear provides a clear visual field for the surgeon. Additionally, by creating an incision behind the ear, no scar formation occurs on the face and neck. The skin flap is also thicker and less prone to complications such as necrosis. Our modified endoscopic, partial-superficial parotidectomy surgery provided favorable cosmetic outcomes and preserved parotid gland function.
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ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Acknowledgment The authors thank Yiqing Zheng, MD, Department of Otolaryngology, Second Affiliated Hospital of Sun Yat-sen University, for revising the manuscript.
Disclosure Statement The authors have no conflicts of interest or financial ties to disclose.
References 1 2 3 4 5 6 7 8 9 10 11 12 13
Sun W, Xu YD, Zheng YQ, Liu X, Zeng L, Liu W, Huang X: Endoscope-assisted partial-superficial parotidectomy through two small skin incisions. Acta Otolaryngol 2009;129:1493–1497. Huang X, Zheng Y, Liu X, Sun W, Zeng L, Cai X, Liu W, Xu Y, Zhang Z, Huang H: A comparison between endoscopeassisted partial parotidectomy and conventional partial parotidectomy. Otolaryngol Head Neck Surg 2009; 140:70–75. Lohuis PJ, Tan ML, Bonte K, van den Brekel MW, Balm AJ, Vermeersch HB: Superficial parotidectomy via facelift incision. Ann Otol Rhinol Laryngol 2009;118:276–280. O’Brien CJ: Current management of benign parotid tumors – the role of limited superficial parotidectomy. Head Neck 2003;25:946–952. Chen LS, Sun W, Wu PN, Zhang SY, Xu MM, Luo XN, Zhan JD, Huang X: Endoscope-assisted versus conventional second branchial cleft cyst resection. Surg Endosc 2012;26:1397–1402. Liu J, Song T, Xu M: Minimally invasive video-assisted versus conventional open thyroidectomy: a systematic review of available data. Surg Today 2012;42:848–856. Kim HS, Chung SM, Pae SY, Park HS: Endoscope assisted submandibular sialadenectomy: the face-lift approach. Eur Arch Otorhinolaryngol 2011;268:619–622. Lin SD, Tsai CC, Lai CS, Lee SS, Chang KP: Endoscope-assisted parotidectomy for benign parotid tumors. Ann Plast Surg 2000;45:269–273. Xie L, Zhang D, Lu MM, Gao BM: Minimally invasive endoscopic-assisted resection of benign tumors in the accessory parotid gland: 5 case studies. Head Neck 2012;34:1194–1197. Li B, Zhang L, Zhao Z, Shen G, Wang X: Minimally invasive endoscopic resection of benign tumours of the accessory parotid gland: an updated approach. Br J Oral Maxillofac Surg 2013;51:342–346. Chen MK, Chang CC: Minimally invasive endoscope-assisted parotidectomy: a new approach. Laryngoscope 2007;117:1934–1937. Jackson LL, Gourin CG, Thomas DS, Porubsky ES, Klippert FN, Terris DJ: Use of the harmonic scalpel in superficial and total parotidectomy for benign and malignant disease. Laryngoscope 2005;115:1070–1073. Witt RL: Minimally invasive surgery for parotid pleomorphic adenoma. Ear Nose Throat J 2005; 84: 308, 310–311.
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
© 2014 S. Karger AG, Basel 0301–1569/14/0763–0121$39.50/0 www.karger.com/orl
Original Paper
Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision Junming Chen Sucheng Tang
Weixiong Chen Yuejian Wang
Jianli Zhang
Fayao He
Zhaofeng Zhu
Department of Otolaryngology, First People’s Hospital of Foshan, Foshan, PR China
Key Words Endoscope · Partial-superficial parotidectomy · Tumor Abstract Objectives: The aim of this study was to evaluate the feasibility of an endoscope-assisted partial parotidectomy through a modified retroauricular incision. Patients and Methods: Thirty patients with benign parotid superficial lobe tumors with a diameter of 2.4 ± 0.5 cm, located in the anterior portion of the inferior auricular lobule, underwent an endoscope-assisted partial-superficial parotidectomy. A retrograde approach through a small skin incision was used. An additional 30 patients who underwent conventional surgeries were used as controls. The operation time, operative bleeding volume and subjective satisfaction with the incision scar were compared between the groups. Results: All operations were successfully performed. The endoscopic surgery duration (74.8 ± 15.7 min), bleeding volume (12.7 ± 3.9 ml) and incision length (4.8 ± 0.4 cm) differed between the groups (p = 0.001). The mean patient satisfaction score was 8.6 ± 1.2 in the endoscope-assisted surgery group and 5.4 ± 1.3 in the control group (p = 0.001). There were no tumor recurrences during the 9–36 months of followup. Conclusion: Endoscope-assisted partial-superficial parotidectomy via a modified retroauricular incision is a feasible method for the treatment of benign parotid superficial lobe tumors located in the anterior portion of the inferior auricular lobule. The main advantage of this procedure was that the small operative scars improved the cosmetic results. © 2014 S. Karger AG, Basel
J.C. and W.C. contributed equally to this work. Yuejian Wang, MD, PhD Department of Otolaryngology First People’s Hospital of Foshan Foshan 528000 (PR China) E-Mail wangyuejian1997 @ 163.com
122
ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Introduction
Benign parotid gland tumors account for the majority of parotid gland neoplasms [1]. The recommended treatment for small benign tumors located in the superficial parotid gland lobe is a partial-superficial parotidectomy; however, conventional parotid surgeries leave a large S- or Y-shaped scar [2]. Additionally, the large wounds and the wide operative areas associated with these procedures have created concerns for many patients, and a long incision with attendant scarring is difficult to accept for most patients [3]. Therefore, an alternative method with improved aesthetics is needed to meet the patients’ increasing cosmetic demands. Endoscopic surgery, such as endoscopic thyroidectomy, has been used frequently on the head and neck. One of the advantages of this type of surgery is that it leaves a smaller postoperative scar compared with the conventional approach [2]. In this study, we present a new endoscope-assisted partial-superficial parotidectomy approach through one small skin incision that improves the cosmetic results. Patients and Methods From February 2009 to August 2012, 30 patients with benign parotid tumors were selected to undergo an endoscope-assisted partial-superficial parotid surgery. The group consisted of 15 males and 15 females. The patients ranged in age from 30 to 65 years (mean age: 48). The control group consisted of 17 males and 13 females with a mean age of 47 years (range: 30–64) who underwent a conventional surgery. Both groups of patients were matched on age, sex and tumor volume (table 1). Their clinical symptoms and physical signs included painless tumors anterior or inferior to the auricular lobules. The tumor surfaces were smooth with clear borders. The endoscope-assisted parotid surgery method was explained to all patients and their families before the operation, and their consent was obtained. The Foshan Hospital of Yat-sen University Institutional Review Board approved this study. All patients underwent either a CT scan or MRI before the operation (fig. 1a, b). The indication for an endoscopic parotidectomy was a parotid superficial lobe neoplasm with a 30 mm maximum diameter located at the anterior or inferior portions of the auricular lobule. Patients with a suspected malignant parotid tumor, acute inflammatory stage sialadenitis, a radiotherapy history, preexisting facial paresis or a recurrent tumor were excluded. The patients were placed in the supine position with a pillow under a shoulder. Additionally, all 30 patients received general anesthesia. The operating team consisted of the chief surgeon, the endoscope assistant and a scrub nurse. A skin incision was made during the surgery. The incision went from the trailing edge of the ear lobe ditch up approximately 2.0–2.5 cm and was curved, extending approximately 2–3 cm to the mastoid. The total incision length was 4.0–5.5 cm. The incision did not exceed the hairline, and the lowest region was set above the earlobe (fig. 1c). The working space was produced by elevating the skin flap with self-designed, custom-made retractors to establish a stable operative space (fig. 2a). The tissue under the platysma was dissected using an electrotome or an ultrasonic scalpel (Ethicon Endo-Surgery, Shanghai, China) at a power level of three. The incision clearly exposed the anterior superficial lobule border of the parotid gland. The parotid tissue was then dissected away from the sternocleidomastoid. Notably, the great auricular nerve was protected under the 4-mm diameter, 0°-angle endoscope (Karl-Storz, Tuttlingen, Germany). After dissection between the skin flap and the superficial parotid gland lobe, the main facial nerve trunk was identified (fig. 2b). The major landmark for the main facial nerve trunk identification was the tympanomastoid fissure. Additionally, the peripheral facial nerve branches were dissected by dividing the glandular tissue. Due to the endoscope amplification, the facial nerve branches were clearly identified (fig. 2b). After the facial nerve exposure, the parenchymal dissection could be performed safely. The tissue specimens were sent for frozen sectioning, and the results demonstrated that all tumors were benign. As the cervical facial nerve trunk was exposed, the tumor was excised together with a normal parotid parenchyma margin of 0.5–1 cm. For the final histologic examinations, all specimens were sent for paraffin sectioning. Finally, the wound was closed with 4-0 Dexon subcuticular sutures, and a small ventricular drainage tube was placed for drainage. The conventional operation procedure was the same as previously described [4].
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ORL 2014;76:121–126 © 2014 S. Karger AG, Basel www.karger.com/orl
DOI: 10.1159/000362605
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Table 1. Comparison of endoscope-assisted and conventional surgeries
Male/female, n Age, years Pleomorphic adenoma/Warthin’s tumor, n Incision length, cm Operative bleeding volume, ml Operation time, min Tumor diameter, cm Subjective satisfaction with incision scar (VAS)
Endoscope-assisted surgery (n = 30)
Conventional surgery (n = 30)
p value
15/15 48 ± 11 19/11 4.8 ± 0.4 12.7 ± 3.9 74.8 ± 15.7 2.4 ± 0.5 8.6 ± 1.2
17/13 47 ± 12 21/9 12.2 ± 1.4 31.0 ± 8.9 103.2 ± 10.3 2.5 ± 0.4 5.4 ± 1.3
0.60 0.66 0.89 0.001* 0.001* 0.001* 0.46 0.001*
a
Color version available online
Values are represented as mean ± SD, unless otherwise specified. * p < 0.05.
c
b
a
b
c
Color version available online
Fig. 1. CT and incision. a, b In 1 patient, a solid lesion (white arrows) with a clear margin was found by a CT scan of the right accessory gland. c The concealed incision (black arrow) started from the trailing edge of the ear lobe ditch up approximately 2.0–2.5 cm and then turned downwards to the mastoid. The incision did not exceed the hairline, and the lowest level observed was above the earlobe.
Fig. 2. Tumor resection through a retroauricular incision and the subsequent scar formation following surgery. a The working space was constructed after the tissue under the platysma was undermined by a blunt and sharp dissection. It was produced by elevating the skin flap with self-designed, custom-made retractors. b The main facial nerve trunk (white arrow) was dissected and then exposed, and the main facial nerve branches (black arrows) were dissected. c The small postoperative scar was concealed in the postauricular area, resulting in an improved cosmetic result. A postoperative photograph of case 1 illustrates the pleasing aesthetic results with concealed incision scars 9 months following surgery.
124
ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Statistical Analysis The outcomes of the two groups were compared in terms of operation time, operative bleeding volume and subjective satisfaction. Additionally, the incision scars were evaluated 6 months after the surgeries using a visual analog scale (VAS) that ranged from 0 to 10, with a higher score representing greater patient satisfaction [5]. The operative time was defined as the time from incision to closure. The data for each group were expressed as mean ± standard deviation (SD). Statistical comparisons between the two groups were performed with Student’s t tests using SPSS 16.0 (SPSS Inc., Chicago, Ill., USA) for Windows. p < 0.05 was regarded as statistically significant.
Results
All 30 operations were successfully performed endoscopically, and no conversions to a conventional open resection were necessary. The postoperative pathological examinations showed 11 Warthin’s tumor cases and 19 pleomorphic adenoma cases. The pathology also proved that complete tumor removal was achieved in all cases. All resection margins were free from tumor invasion within 0.5–1 cm. The operating time was 74.8 ± 15.7 min (range: 60–110), and the bleeding volume was 12.7 ± 3.9 ml (range: 10–20). The patients were discharged on the next postoperative day following drainage tube removal. Only 1 patient developed transient facial paresis after the endoscope-assisted surgery and recovered within 1 month. None of the patients developed capsular ruptures, salivary fistulas or Frey syndrome. All patients were disease-free, and the follow-ups occurred between 9 and 36 months (mean: 23). In the conventional surgery group, the operating time was 103.2 ± 10.3 min (range: 80–117) and the bleeding volume was 31.0 ± 8.9 ml (range: 20–50). Using a t test analysis, the endoscopic surgery bleeding volumes were smaller than those observed in the conventional surgeries (p = 0.001), and the operation times were shorter than those of the control group (p = 0.001). On a VAS, the mean patient satisfaction score regarding the incision scars was much higher in the endoscopeassisted group compared with the control group (p = 0.001) (table 1). There were no scar formations observed on the face and neck because of the retroauricular incisions (fig. 2c). Discussion
Conventional parotid surgery is performed using an S-shaped or Y-shaped skin incision to allow for complete tumor resection with safe facial nerve dissection; however, this surgery leaves a large scar. The long incision and wide exposure of the operative area due to these procedures frequently create discomfort for most patients. Thus, the function of many parotid and cosmetic surgery scholars has been to develop new surgical techniques. Endoscopy has been used in thyroid [6], submandibular gland [7] and branchial cleft cyst surgeries [5]. The successful application of endoscopies during neck surgery made parotid endoscopic surgery possible. Lin et al. [8] first reported 16 endoscopic-assisted parotidectomy cases using a modified ‘S’-incision, and although the incision narrowed, it was still visible. Additionally, Xie et al. [9] reported five single-incision surgery cases that were anterior to the tragus for superficial benign tumor parotidectomies. A single incision, however, was only suitable for tumors located in the tragus region and not for tumor resection under the earlobe. Sun et al. [1] used an ear plus a mandibular incision for parotid tumor resections in the superficial lobe. Li et al. [10] adopted an incision under the tragus lobe for benign tumors in the parotid superficial lobe; however, both jaw and ear incisions were visible, and two-incision surgeries increased trauma. Chen and Chang [11] used a 3.1-cm long retroauricular incision that was more subtle. These authors achieved excellent cosmetic results, but because the field of view is narrow, this approach is only suitable for benign tumors in the caudal lobe.
125
ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
We used a retroauricular incision located 2.0–2.5 cm above the earlobe behind the ear that was curved and extended approximately 2–3 cm. The incision length was 4.0–5.5 cm, and the lowest point of the incision was never lower than the earlobe. The incision length was much shorter than that of the control group, and there was no scar formation on the face and neck; therefore, we achieved better cosmetic results. Because of the endoscopic technique, almost all superficial parotid gland areas were exposed, except the anterior portion. The upper part of the tragus has a low parotid tumor incidence rate [2]; thus, this approach is suitable for most benign superficial parotid gland tumors. Additionally, the surgical flap aspect ratio was small, and the flap was thicker. Moreover, the thicker flap has a smaller risk for necrosis [5]. In the present study, there were no flap necrosis or postoperative color change cases. Facial paralysis is one of the most common parotid surgery complications, and protecting the facial nerve during surgery is particularly important. With endoscopic lighting and amplification, the facial nerve trunk is easier to identify [2]. Additionally, when coupled with the ultrasonic scalpel, it was easy to occlude blood vessels, which resulted in less bleeding, an improved vision and a decreased risk of lesions on facial nerve branches in our endoscope-assisted group. There was only one postoperative temporary paralysis case of the marginal mandibular facial nerve branch in our study, and there were no permanent facial paralysis cases. Our results were consistent with the Sun et al. report [1], while this surgery also had the advantage of preserving facial nerves. Furthermore, the total operation time of our surgery was considerably shorter than that of conventional surgeries because of the harmonic scalpel use. The harmonic scalpel cuts and coagulates via ultrasonic blade vibrations at 55,000 Hz, which denatures proteins and forms a coagulum that seals the vessels. Vessels up to 5 mm in diameter can be sealed by coaptation. Thus, the operative field is clean and bloodless, and accidental injury or facial nerve branch abrasions can be avoided [12]. In our study, the bleeding volume was smaller than that of the conventional group. These results indicate that our surgery also had the advantage of reduced bleeding. In the present study, we completed benign parotid tumor resections and removed tumor margins (0.5–1 cm of normal parotid tissue) to ensure an adequate safety margin and prevent recurrence. O’Brien [4] reported 363 limited (partial) superficial benign neoplasm parotidectomies, and their recurrence rate was only 0.8% with a median postoperative period of 6 years. O’Brien [4] concluded that limited superficial parotidectomy is associated with very low morbidity and recurrence rates and that complete superficial parotidectomy is not warranted for benign localized parotid tumor treatment. In another study, Witt [13] reported that a 1-cm area of normal parotid parenchyma around a benign pleomorphic adenoma was a safe margin. The surgical treatment outcomes (capsular exposure, tumor-facial nerve interface, capsular rupture, recurrence, facial nerve dysfunction and Frey’s syndrome) of mobile, superficial parotid gland lobes smaller than 4 cm were not significantly altered by the surgical approach (total-superficial parotidectomy, partial-superficial parotidectomy or extracapsular dissection). Therefore, partial parotidectomy is an adequate treatment for pleomorphic parotid gland adenomas. In the present study, the surgical margin was 0.5–1 cm, and there was no recurrence during the follow-up. These results are consistent with those of Sun et al. [1] and Huang et al. [2], indicating that the surgery caused a low recurrence rate. Conclusion
Improved endoscopic-assisted surgery using a small incision behind the ear provides a clear visual field for the surgeon. Additionally, by creating an incision behind the ear, no scar formation occurs on the face and neck. The skin flap is also thicker and less prone to complications such as necrosis. Our modified endoscopic, partial-superficial parotidectomy surgery provided favorable cosmetic outcomes and preserved parotid gland function.
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ORL 2014;76:121–126 DOI: 10.1159/000362605
© 2014 S. Karger AG, Basel www.karger.com/orl
Chen et al.: Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision
Acknowledgment The authors thank Yiqing Zheng, MD, Department of Otolaryngology, Second Affiliated Hospital of Sun Yat-sen University, for revising the manuscript.
Disclosure Statement The authors have no conflicts of interest or financial ties to disclose.
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