Acta Oto-Laryngologica. 2015; 135: 718–721
ORIGINAL ARTICLE
The role of partial parotidectomy for benign parotid tumors: A case-control study
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
GUILLERMO PLAZA, ELIZABETH AMARILLO, ESTEFANÍA HERNÁNDEZ-GARCÍA & MÓNICA HERNANDO Hospital Universitario de Fuenlabrada, Madrid, Spain
Abstract Objective: To evaluate the results and complications after partial parotidectomy vs superficial parotidectomy, as primary treatment of benign parotid tumors. Study design: Case-control study. Setting: University hospital. Subjects and methods: A casecontrol study is presented on parotidectomy, comparing a group of 25 patients treated by partial parotidectomy vs a similar group of 25 patients treated by superficial parotidectomy. All patients had primary benign parotid tumors, were matched by sex and age, and had a minimum follow-up of 4 years. Independent variables included sex, age, medical history, intra-operative variables (surgical time, estimated blood loss, type of drainage, use of collagen), fine-needle aspiration cytology, computed tomography findings, and final histopathological diagnosis. Outcome measures were early and late complications, such as facial nerve paralysis, seroma, sialocele, Frey syndrome, and recurrence. Results: Partial parotidectomy resulted in less early and late complications than superficial parotidectomy, with similar recurrence rates. Temporal facial paresis was found in 4% of partial surgeries, vs 12% of superficial parotidectomies, a significant difference. Three months after surgery, only one patient has a persistent marginal nerve paresis. In contrast, sialocele was more common after partial parotidectomy (28% vs 16%), a significant difference. Conclusions: Partial parotidectomy achieves less early and late complications than superficial parotidectomy, with similar recurrence rates.
Keywords: Superficial parotidectomy, partial parotidectomy, pleomorphic adenoma, facial nerve paralysis
Introduction Parotid tumors usually present as painless slowly growing lumps, and most of these are benign, with pleomorphic adenoma accounting for 60–70% of parotid tumors [1,2]. Parotid pleomorphic adenoma (PPA) is most often diagnosed and treated when the tumor is small (less than 4 cm), mobile, and located in the superficial lobe, lying lateral to the facial nerve. Before 1940, management of PPA consisted predominantly of local excision, so called enucleation, by a rapid ‘shelling out’ of the lump with a limited exposure, and a high risk of tumor rupture and sub-total removal, with recurrence rates from 20– 45%. Thereafter, the most widely accepted method of managing such tumors has been superficial (lateral
or suprafacial) parotidectomy (SP) with full facial nerve dissection; it has reduced recurrence rates to 1–4% in most series, but also has caused more facial paresis and other complications [3,4]. Total parotidectomy (TP) is another option, especially for bigger tumors, or those located deeper to the facial nerve, but this requires that all parotid tissue lateral and medial to the facial nerve is removed. Over the last years, two other surgical techniques have been advocated in order to shorten the procedure and to reduce post-operative complications: Partial superficial parotidectomy (PSP) dissects less than the full facial nerve, and removes a generous cuff of surrounding parotid tissue, but does not sacrifice normal parotid tissue distant from the tumor [5–9]. Extracapsular dissection (ECD) requires meticulous
Correspondence: Dr Guillermo Plaza, Otolaryngology Department, Hospital de Fuenlabrada, Co del Molino, 2, Fuenlabrada 28942, Madrid, Spain. Fax: +34916006186. E-mail: gplaza.hfl[email protected]
(Received 9 December 2014; accepted 3 February 2015) ISSN 0001-6489 print/ISSN 1651-2251 online 2015 Informa Healthcare DOI: 10.3109/00016489.2015.1020394
719
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
Partial parotidectomy hemostasis and dissection of a small cuff of normal parotid parenchyma just outside the capsule of the parotid tumor, while facial nerve dissection is not performed [10–12]. Our objective was to evaluate our results and complications after partial parotidectomy vs superficial parotidectomy, as primary treatment of benign parotid tumors.
Frey syndrome, and recurrence. During follow-up visits, patients were regularly asked about the presence of gustatory sweating. Statistical analysis was done after SPSS 10.0, with a 0.05 significance. Comparison of both groups was done by Chi-squared and non-parametric analysis.
Materials and methods
A total of 50 parotidectomy patients were evaluated in this study. Clinical characteristics of both groups of 25 cases (SP and PSP) were designed to be similar through a case-control study, including matched clinical and histopathologic variables (Table I). Correlation of FNAC with histopathological results was observed in 38 cases. The sensitivity and the specificity of FNAC in the detection of the final benign tumor was 46% and 86%, respectively. CT was able to locate the tumor in the superficial lobe, confirm its benign characteristics, and establish its size under 4 cm to be included in this study. After surgery, tumor size was only 2 cm on average in both groups (range = 1.2–3.3 cm). Capsular exposure and/or capsular rupture were reported in two cases (8%) in each group, but its frequency was not statistically different between both groups. Surgical time and estimated blood loss were smaller in the PSP group, but not statistically significant (Table I). Immediate post-operative facial paresis of one or more branches of the nerve was found in 4% of PSP cases vs 12% of SP ones, a significant difference; nevertheless, most of them were rapidly resolved and, 3 months after surgery, only a SP case had a persistent marginal nerve paralysis. Post-operative sialocele, lasting up to 10 days, was more common after PSP (28% vs 16%), also a significant difference (Table II). Frey syndrome was only observed in one SP case. So far, no recurrences have been observed during a minimum follow-up of 4 years (median = 6 years, range = 4–8 years).
A case-control study is presented on parotidectomy, comparing a group of 25 patients treated by PSP vs a similar group of 25 patients treated by SP at a University Hospital. All patients had primary benign parotid tumors, less than 4 cm in size, and located in the superficial lobe, and were assessed by fine-needle aspiration cytology (FNAC) and computed tomography (CT). The Institutional Review Board of our Hospital approved this retrospective study. From our database of salivary tumors compromising more than 200 cases during more than 10 years, a case-control study was designed including 50 patients that were matched by sex, age, and histopathology (19 pleomorphic adenoma, and six Warthin tumors in each group), and had a minimum follow-up of 4 years. Most cases were operated on by the senior author. The surgical technique was done following published guidelines to perform SP or PSP9, with maximal care to preserve facial nerve anatomy and function, with facial nerve intraoperative monitoring (Neurosign Surgical, UK ). A Blair ‘lazy-S’ incision was performed commencing at the front of the ear. Skin flaps were raised and the facial nerve trunk was identified early in the operation using any of the following landmarks: tympanomastoid suture, tragal pointer, and/or posterior belly of digastric. Although attempts were made to preserve the great auricular nerve, in most cases the nerve was sacrificed. The gland was then mobilized in an anterograde fashion from the branches of the facial nerve. Hemostasis was achieved with bipolar diathermy. An en bloc resection with a 1–2 cm margin of normal surrounding parotid tissue was intended in all cases, but capsular exposure, tumor–facial nerve interface, and capsular rupture were reported during surgery. Surgical time and estimated blood loss were also recorded. Surgical prevention of Frey syndrome, sialocele, and seroma included in both groups the use collagen sponges (Willospon, Will-Pharma, Netherlands) on the surgical field, and of drainage during the first 24 h, with a 24-h stay in hospital. Outcome measures were early (first month) and late complications (over 3 months) after surgery, such as facial nerve paresia or paralysis, seroma or sialocele,
Results
Table I. Clinical characteristics of superficial parotid tumors in each group. SP (n = 25)
PSP (n = 25)
Age (SD)
42 (8)
43 (7)
Sex (M/F)
15/10
15/10
2.1 (0.6)
2.0 (0.3)
19/6
19/6
Tumor size, cm (SD) Pathology (Pleomorphic/Warthin) Capsular rupture Surgical time, minutes (SD) Estimated blood loss over 200 cc
2
2
126 (36)
112 (24)
6
4
PSP, partial superficial parotidectomy; SP, superficial parotidectomy; SD, standard deviation.
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G. Plaza et al.
Table II. Post-operative complications after parotidectomy. Post-op complications
SP (n = 25) PSP (n = 25)
2
Chi
Early (first 4 weeks) Facial paresis
12%
4%
p < 0.05
Seroma
16%
28%
p < 0.05
Hematoma
4%
—
p > 0.05
Dehiscence
4%
—
p > 0.05
Marginal nerve paralysis
4%
—
p > 0.05
Frey syndrome
4%
—
p > 0.05
Keloid scarring
4%
—
p > 0.05
—
—
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
Late (after 4 weeks)
Recurrence PSP, partial parotidectomy.
superficial
parotidectomy;
SP,
— superficial
Discussion This case-control study was designed to compare the efficacy and complications after partial parotidectomy vs superficial parotidectomy, as a primary treatment of benign parotid tumors. Both surgical techniques were effective, with no tumor recurrence during the follow-up period. Local recurrences seem to be very rare in benign small parotid tumors. Witt [8] has thoroughly reviewed recurrences that were reported in the literature, and most were observed within the first years of follow-up, although they may appear after 10 years too. This low incidence of recurrence has made some authors suggest that prolonged follow-up, after the first 2 years, might be unnecessary [2,5,12]. Most authors agree that follow-up should be longer, over 10 years, especially on tumors over 4 cm in size [1,3]. Capsular exposure and/or rupture have been reported in pleomorphic adenomas of the parotid gland, due to tumor invasion or projection beyond their macroscopic boundaries into normal tissues [3,4,13,14]. Although these findings have been reported in more than half of parotid specimens, especially in prospective pathologic series studying whole-organ sections [14], their significance is controversial, because recurrences of the tumor after conventional SP are much less common [7,10]. Our results showed that a limited resection of the superficial lobe of the parotid, including a generous cuff of surrounding parotid tissue, is able to avoid recurrences, is able to treat most small benign tumors, with only 8% of capsular exposure or rupture, as previously reported [5,8,10]. Nevertheless, as Quer et al. [15] suggest, surgical reports should describe precisely which areas of the parotid gland
have been resected, not only to enable one to perform correct comparisons of different series, but also to help future surgeons who might have to treat our recurrences. One of the potential advantages of PSP is to avoid complications [8,9,11]. Temporary facial paresis is less common after PSP than after conventional SP, probably because it avoids unnecessary sacrifice of normal parotid tissue distant from the tumor, and allows adequate preservation of facial branches [5–11]. Our results on facial paresis are similar to those published in the literature (15–20%) [2,3,7,12], with temporary paresis in 12% of SP patients, and only 4% after PSP. Nevertheless, post-operative sialocele is more common after limited parotidectomy. Our series shows temporary sialocele, lasting up to 10 days and requiring periodic aspirations, in 28% of PSP. The presence of more remaining salivary tissue after limited surgery may cause more salivary drainage, as compared to SP or total parotidectomy. This finding has also been reported by Upton et al. [2], who found that most of their post-operative sialoceles were after PSP, and by Witt [16], with up to 39% of cases with sialocele after PSP compared to 0% after near-total parotidectomy. Herbert and Morton [17] have also reported that up to 20% of parotid surgeries may develop a sialocele, and that this complication was related to the use of Surgicel. Surgical prevention of Frey syndrome is regularly based on classical reconstruction techniques such as SMAS or SCM flaps. These reconstructions are timeconsuming, whereas the use of collagen sponges (Willospon, Will-Pharma, Netherlands) on the surgical field is a simple straightforward way to obtain the same separation between the surgical field and the skin above it, as has also been described after alloderm [18]. Witt [8] presented a retrospective series of small pleomorphic adenomas of the parotid including 60 cases treated by TP, PSP, or ECD (20 in each group), and an extensive meta-analysis showing that focal capsular exposure occurs in virtually all parotid surgery for such a tumor, regardless of the type of operation (margin). In his study, less parotid tissue sacrifice did not result in a lower rate of permanent facial nerve dysfunction, although it did result in significantly less transient facial nerve dysfunction and Frey syndrome. Such meta-analysis confirmed the potential value of limited parotid surgery in small benign parotid tumors, when a generous cuff of surrounding parotid tissue is also removed to avoid recurrences [8]. Tuckett et al. [19] have recently have conducted a prospective study of 66 consecutive parotidectomies.
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
Partial parotidectomy They have also shown that less extensive parotid resection seems to be associated with a higher incidence of post-operative sialocele and salivary fistula, but is also associated with less post-operative facial nerve dysfunction. Roh et al. [12] have reported on a randomized clinical trial comparing PSP vs SP on 100 patients with benign parotid tumors. They have shown that the mean duration of operation was 0.7 h shorter and the overall complication rate significantly lower in the PSP group. In this group, transient facial paralysis and Frey’s syndrome were infrequent (12% and 6%, respectively). They concluded that, compared with conventional procedures, function-preserving surgery for benign parotid tumors improved cosmetic, sensory, and salivary functions, and reduced the duration of surgery and operative morbidity. Our design is less strong than a randomized trial, but this well-matched case-control study was also able to establish adequate and similar statistic conclusions. Therefore, complete removal of benign parotid tumors with preservation of an intact facial nerve should be our goal when treating every patient [9]. As Mantsopoulos et al. [20] have reported, this can be accomplished by limited parotidectomy, with less morbidity than superficial parotidectomy, especially in small benign parotid tumors, less than 4 cm of size, and located in the superficial lobe.
[3]
[4]
[5]
[6]
[7]
[8] [9]
[10]
[11]
[12]
[13]
Conclusion Partial parotidectomy has a role in management of small (less than 4 cm of size) benign parotid tumors. It achieves less early and late complications than superficial parotidectomy, with similar recurrence rates, although sialocele is more common after partial parotidectomy.
[14]
[15]
[16]
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[17]
[18]
References [1] Guntinas-Lichius O, Kick C, Klussmann JP, Jungehuelsing M, Stennert E. Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 2004;261:143–6. [2] Upton DC, McNamar JP, Connor NP, Harari PM, Hartig GK. Parotidectomy: ten-year review of 237 cases at
[19]
[20]
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a single institution. Otolaryngol Head Neck Surg 2007;136: 788–92. Guntinas-Lichius O, Klussmann JP, Wittekindt C, Wittekindt C, Stennert E. Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 2006;116:534–40. Donovan DT, Conley JJ. Capsular significance in parotid tumor surgery: reality and myths of lateral lobectomy. Laryngoscope 1984;94:324–9. Yamashita T, Tomoda K, Kumazawa T. The usefulness of partial parotidectomy for benign parotid gland tumors. A retrospective study of 306 cases. Acta Otolaryngol Suppl 1993;500:113–16. Iizuka K, Ishikawa K. Surgical techniques for benign parotid tumors: segmental resection vs extracapsular lumpectomy. Acta Otolaryngol Suppl 1998;537:75–81. Witt RL. Facial nerve function after partial superficial parotidectomy: an 11-year review (1987-1997). Otolaryngol Head Neck Surg 1999;121:210–13. Witt RL. The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 2002;112:2141–54. Johnson JT, Ferlito A, Fagan JJ, Bradley PJ, Rinaldo A. Role of limited parotidectomy in management of pleomorphic adenoma. J Laryngol Otol 2007;121:1126–8. McGurk M, Renehan A, Gleave EN, Hancock BD. Clinical significance of the tumour capsule in the treatment of parotid pleomorphic adenomas. Br J Surg 1996;83:1747–9. Smith SL, Komisar A. Limited parotidectomy: the role of extracapsular dissection in parotid gland neoplasms. Laryngoscope 2007;117:1163–7. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus superficial or total parotidectomy. Br J Surg 2007;94:1081–7. Stennert E, Guntinas-Lichius O, Klussmann JP, Arnold G. Histopathology of pleomorphic adenoma in the parotid gland: a prospective unselected series of 100 cases. Laryngoscope 2001;111:2195–200. Zbären P, Stauffer E. Pleomorphic adenoma of the parotid gland: histopathologic analysis of the capsular characteristics of 218 tumors. Head Neck 2007;29:751–7. Quer M, Pujol A, León X, López M, García J, Orús C, et al. Parotidectomies in benign parotid tumours: ‘Sant Pau’ surgical extension classification. Acta Otorrinolaringol Esp 2010;61:1–5. Witt RL. Incidence and management of sialocele post parotidectomy. Otolaryngol Head Neck Surg 2009;140: 871–4. Herbert HA, Morton RP. Sialocele after parotid surgery: assessing the risk factors. Otolaryngol Head Neck Surg 2012; 147:489–92. Athavale SM, Phillips S, Mangus B, Datta J, Sinard RJ, Netterville JL, et al. Complications of alloderm and dermamatrix for parotidectomy reconstruction. Head Neck 2012; 34:88–93. Tuckett J, Glynn R, Sheahan P. Impact of extent of parotid resection on postoperative wound complications: a prospective study. Head Neck 2015;37:64–8. Mantsopoulos K, Koch M, Klintworth N, Zenk J, Iro H. Evolution and changing trends in surgery for benign Parotid tumors. Laryngoscope 2015;125:122–7.
ORIGINAL ARTICLE
The role of partial parotidectomy for benign parotid tumors: A case-control study
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
GUILLERMO PLAZA, ELIZABETH AMARILLO, ESTEFANÍA HERNÁNDEZ-GARCÍA & MÓNICA HERNANDO Hospital Universitario de Fuenlabrada, Madrid, Spain
Abstract Objective: To evaluate the results and complications after partial parotidectomy vs superficial parotidectomy, as primary treatment of benign parotid tumors. Study design: Case-control study. Setting: University hospital. Subjects and methods: A casecontrol study is presented on parotidectomy, comparing a group of 25 patients treated by partial parotidectomy vs a similar group of 25 patients treated by superficial parotidectomy. All patients had primary benign parotid tumors, were matched by sex and age, and had a minimum follow-up of 4 years. Independent variables included sex, age, medical history, intra-operative variables (surgical time, estimated blood loss, type of drainage, use of collagen), fine-needle aspiration cytology, computed tomography findings, and final histopathological diagnosis. Outcome measures were early and late complications, such as facial nerve paralysis, seroma, sialocele, Frey syndrome, and recurrence. Results: Partial parotidectomy resulted in less early and late complications than superficial parotidectomy, with similar recurrence rates. Temporal facial paresis was found in 4% of partial surgeries, vs 12% of superficial parotidectomies, a significant difference. Three months after surgery, only one patient has a persistent marginal nerve paresis. In contrast, sialocele was more common after partial parotidectomy (28% vs 16%), a significant difference. Conclusions: Partial parotidectomy achieves less early and late complications than superficial parotidectomy, with similar recurrence rates.
Keywords: Superficial parotidectomy, partial parotidectomy, pleomorphic adenoma, facial nerve paralysis
Introduction Parotid tumors usually present as painless slowly growing lumps, and most of these are benign, with pleomorphic adenoma accounting for 60–70% of parotid tumors [1,2]. Parotid pleomorphic adenoma (PPA) is most often diagnosed and treated when the tumor is small (less than 4 cm), mobile, and located in the superficial lobe, lying lateral to the facial nerve. Before 1940, management of PPA consisted predominantly of local excision, so called enucleation, by a rapid ‘shelling out’ of the lump with a limited exposure, and a high risk of tumor rupture and sub-total removal, with recurrence rates from 20– 45%. Thereafter, the most widely accepted method of managing such tumors has been superficial (lateral
or suprafacial) parotidectomy (SP) with full facial nerve dissection; it has reduced recurrence rates to 1–4% in most series, but also has caused more facial paresis and other complications [3,4]. Total parotidectomy (TP) is another option, especially for bigger tumors, or those located deeper to the facial nerve, but this requires that all parotid tissue lateral and medial to the facial nerve is removed. Over the last years, two other surgical techniques have been advocated in order to shorten the procedure and to reduce post-operative complications: Partial superficial parotidectomy (PSP) dissects less than the full facial nerve, and removes a generous cuff of surrounding parotid tissue, but does not sacrifice normal parotid tissue distant from the tumor [5–9]. Extracapsular dissection (ECD) requires meticulous
Correspondence: Dr Guillermo Plaza, Otolaryngology Department, Hospital de Fuenlabrada, Co del Molino, 2, Fuenlabrada 28942, Madrid, Spain. Fax: +34916006186. E-mail: gplaza.hfl[email protected]
(Received 9 December 2014; accepted 3 February 2015) ISSN 0001-6489 print/ISSN 1651-2251 online 2015 Informa Healthcare DOI: 10.3109/00016489.2015.1020394
719
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
Partial parotidectomy hemostasis and dissection of a small cuff of normal parotid parenchyma just outside the capsule of the parotid tumor, while facial nerve dissection is not performed [10–12]. Our objective was to evaluate our results and complications after partial parotidectomy vs superficial parotidectomy, as primary treatment of benign parotid tumors.
Frey syndrome, and recurrence. During follow-up visits, patients were regularly asked about the presence of gustatory sweating. Statistical analysis was done after SPSS 10.0, with a 0.05 significance. Comparison of both groups was done by Chi-squared and non-parametric analysis.
Materials and methods
A total of 50 parotidectomy patients were evaluated in this study. Clinical characteristics of both groups of 25 cases (SP and PSP) were designed to be similar through a case-control study, including matched clinical and histopathologic variables (Table I). Correlation of FNAC with histopathological results was observed in 38 cases. The sensitivity and the specificity of FNAC in the detection of the final benign tumor was 46% and 86%, respectively. CT was able to locate the tumor in the superficial lobe, confirm its benign characteristics, and establish its size under 4 cm to be included in this study. After surgery, tumor size was only 2 cm on average in both groups (range = 1.2–3.3 cm). Capsular exposure and/or capsular rupture were reported in two cases (8%) in each group, but its frequency was not statistically different between both groups. Surgical time and estimated blood loss were smaller in the PSP group, but not statistically significant (Table I). Immediate post-operative facial paresis of one or more branches of the nerve was found in 4% of PSP cases vs 12% of SP ones, a significant difference; nevertheless, most of them were rapidly resolved and, 3 months after surgery, only a SP case had a persistent marginal nerve paralysis. Post-operative sialocele, lasting up to 10 days, was more common after PSP (28% vs 16%), also a significant difference (Table II). Frey syndrome was only observed in one SP case. So far, no recurrences have been observed during a minimum follow-up of 4 years (median = 6 years, range = 4–8 years).
A case-control study is presented on parotidectomy, comparing a group of 25 patients treated by PSP vs a similar group of 25 patients treated by SP at a University Hospital. All patients had primary benign parotid tumors, less than 4 cm in size, and located in the superficial lobe, and were assessed by fine-needle aspiration cytology (FNAC) and computed tomography (CT). The Institutional Review Board of our Hospital approved this retrospective study. From our database of salivary tumors compromising more than 200 cases during more than 10 years, a case-control study was designed including 50 patients that were matched by sex, age, and histopathology (19 pleomorphic adenoma, and six Warthin tumors in each group), and had a minimum follow-up of 4 years. Most cases were operated on by the senior author. The surgical technique was done following published guidelines to perform SP or PSP9, with maximal care to preserve facial nerve anatomy and function, with facial nerve intraoperative monitoring (Neurosign Surgical, UK ). A Blair ‘lazy-S’ incision was performed commencing at the front of the ear. Skin flaps were raised and the facial nerve trunk was identified early in the operation using any of the following landmarks: tympanomastoid suture, tragal pointer, and/or posterior belly of digastric. Although attempts were made to preserve the great auricular nerve, in most cases the nerve was sacrificed. The gland was then mobilized in an anterograde fashion from the branches of the facial nerve. Hemostasis was achieved with bipolar diathermy. An en bloc resection with a 1–2 cm margin of normal surrounding parotid tissue was intended in all cases, but capsular exposure, tumor–facial nerve interface, and capsular rupture were reported during surgery. Surgical time and estimated blood loss were also recorded. Surgical prevention of Frey syndrome, sialocele, and seroma included in both groups the use collagen sponges (Willospon, Will-Pharma, Netherlands) on the surgical field, and of drainage during the first 24 h, with a 24-h stay in hospital. Outcome measures were early (first month) and late complications (over 3 months) after surgery, such as facial nerve paresia or paralysis, seroma or sialocele,
Results
Table I. Clinical characteristics of superficial parotid tumors in each group. SP (n = 25)
PSP (n = 25)
Age (SD)
42 (8)
43 (7)
Sex (M/F)
15/10
15/10
2.1 (0.6)
2.0 (0.3)
19/6
19/6
Tumor size, cm (SD) Pathology (Pleomorphic/Warthin) Capsular rupture Surgical time, minutes (SD) Estimated blood loss over 200 cc
2
2
126 (36)
112 (24)
6
4
PSP, partial superficial parotidectomy; SP, superficial parotidectomy; SD, standard deviation.
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G. Plaza et al.
Table II. Post-operative complications after parotidectomy. Post-op complications
SP (n = 25) PSP (n = 25)
2
Chi
Early (first 4 weeks) Facial paresis
12%
4%
p < 0.05
Seroma
16%
28%
p < 0.05
Hematoma
4%
—
p > 0.05
Dehiscence
4%
—
p > 0.05
Marginal nerve paralysis
4%
—
p > 0.05
Frey syndrome
4%
—
p > 0.05
Keloid scarring
4%
—
p > 0.05
—
—
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Late (after 4 weeks)
Recurrence PSP, partial parotidectomy.
superficial
parotidectomy;
SP,
— superficial
Discussion This case-control study was designed to compare the efficacy and complications after partial parotidectomy vs superficial parotidectomy, as a primary treatment of benign parotid tumors. Both surgical techniques were effective, with no tumor recurrence during the follow-up period. Local recurrences seem to be very rare in benign small parotid tumors. Witt [8] has thoroughly reviewed recurrences that were reported in the literature, and most were observed within the first years of follow-up, although they may appear after 10 years too. This low incidence of recurrence has made some authors suggest that prolonged follow-up, after the first 2 years, might be unnecessary [2,5,12]. Most authors agree that follow-up should be longer, over 10 years, especially on tumors over 4 cm in size [1,3]. Capsular exposure and/or rupture have been reported in pleomorphic adenomas of the parotid gland, due to tumor invasion or projection beyond their macroscopic boundaries into normal tissues [3,4,13,14]. Although these findings have been reported in more than half of parotid specimens, especially in prospective pathologic series studying whole-organ sections [14], their significance is controversial, because recurrences of the tumor after conventional SP are much less common [7,10]. Our results showed that a limited resection of the superficial lobe of the parotid, including a generous cuff of surrounding parotid tissue, is able to avoid recurrences, is able to treat most small benign tumors, with only 8% of capsular exposure or rupture, as previously reported [5,8,10]. Nevertheless, as Quer et al. [15] suggest, surgical reports should describe precisely which areas of the parotid gland
have been resected, not only to enable one to perform correct comparisons of different series, but also to help future surgeons who might have to treat our recurrences. One of the potential advantages of PSP is to avoid complications [8,9,11]. Temporary facial paresis is less common after PSP than after conventional SP, probably because it avoids unnecessary sacrifice of normal parotid tissue distant from the tumor, and allows adequate preservation of facial branches [5–11]. Our results on facial paresis are similar to those published in the literature (15–20%) [2,3,7,12], with temporary paresis in 12% of SP patients, and only 4% after PSP. Nevertheless, post-operative sialocele is more common after limited parotidectomy. Our series shows temporary sialocele, lasting up to 10 days and requiring periodic aspirations, in 28% of PSP. The presence of more remaining salivary tissue after limited surgery may cause more salivary drainage, as compared to SP or total parotidectomy. This finding has also been reported by Upton et al. [2], who found that most of their post-operative sialoceles were after PSP, and by Witt [16], with up to 39% of cases with sialocele after PSP compared to 0% after near-total parotidectomy. Herbert and Morton [17] have also reported that up to 20% of parotid surgeries may develop a sialocele, and that this complication was related to the use of Surgicel. Surgical prevention of Frey syndrome is regularly based on classical reconstruction techniques such as SMAS or SCM flaps. These reconstructions are timeconsuming, whereas the use of collagen sponges (Willospon, Will-Pharma, Netherlands) on the surgical field is a simple straightforward way to obtain the same separation between the surgical field and the skin above it, as has also been described after alloderm [18]. Witt [8] presented a retrospective series of small pleomorphic adenomas of the parotid including 60 cases treated by TP, PSP, or ECD (20 in each group), and an extensive meta-analysis showing that focal capsular exposure occurs in virtually all parotid surgery for such a tumor, regardless of the type of operation (margin). In his study, less parotid tissue sacrifice did not result in a lower rate of permanent facial nerve dysfunction, although it did result in significantly less transient facial nerve dysfunction and Frey syndrome. Such meta-analysis confirmed the potential value of limited parotid surgery in small benign parotid tumors, when a generous cuff of surrounding parotid tissue is also removed to avoid recurrences [8]. Tuckett et al. [19] have recently have conducted a prospective study of 66 consecutive parotidectomies.
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Partial parotidectomy They have also shown that less extensive parotid resection seems to be associated with a higher incidence of post-operative sialocele and salivary fistula, but is also associated with less post-operative facial nerve dysfunction. Roh et al. [12] have reported on a randomized clinical trial comparing PSP vs SP on 100 patients with benign parotid tumors. They have shown that the mean duration of operation was 0.7 h shorter and the overall complication rate significantly lower in the PSP group. In this group, transient facial paralysis and Frey’s syndrome were infrequent (12% and 6%, respectively). They concluded that, compared with conventional procedures, function-preserving surgery for benign parotid tumors improved cosmetic, sensory, and salivary functions, and reduced the duration of surgery and operative morbidity. Our design is less strong than a randomized trial, but this well-matched case-control study was also able to establish adequate and similar statistic conclusions. Therefore, complete removal of benign parotid tumors with preservation of an intact facial nerve should be our goal when treating every patient [9]. As Mantsopoulos et al. [20] have reported, this can be accomplished by limited parotidectomy, with less morbidity than superficial parotidectomy, especially in small benign parotid tumors, less than 4 cm of size, and located in the superficial lobe.
[3]
[4]
[5]
[6]
[7]
[8] [9]
[10]
[11]
[12]
[13]
Conclusion Partial parotidectomy has a role in management of small (less than 4 cm of size) benign parotid tumors. It achieves less early and late complications than superficial parotidectomy, with similar recurrence rates, although sialocele is more common after partial parotidectomy.
[14]
[15]
[16]
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[17]
[18]
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