What is the best method for prevention of postparotidectomy Frey syndrome? Network meta-analysis

Mitigating complications rate in parotid gland tumor surgery by reconstruction technique with SurgiMend®: a retrospective, single-center, observational study on 300 consecutive patients

BACKGROUND

Salivary gland tumors have an incidence of 1 out of 100,000 people every year, representing 2-4 % of the head and neck tumors. Consensually, radical surgery is the choice in parotid tumors. Despite improvements in surgical and anatomy-preserving strategies, several complications exist in this surgery. Frey Syndrome is caused by an aberrant regeneration of parasympathetic nerve fibers of the auriculotemporal nerve after parotidectomy.

PURPOSE

The purpose of the present study was to compare the surgical complication rate differences between patients undergone parotid gland tumor surgery with reconstruction performed by traditional methods (Group A), and by SurgiMend (Group B).

STUDY DESIGN, SETTING, AND SAMPLE

The clinical, surgical, and monitoring data of 300 consecutive patients operated at our Institution between 2017 and 2020 were assessed for statistical deductive purposes, shaping a cohort retrospective monocentric observational study.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE/MAIN OUTCOME VARIABLE

The primary outcome variable was the rate of Frey Syndrome. Secondary outcomes were the other complication rates, including surgical site infections, dehiscence, hypertrophic scars, seromas, hematomas, and temporary and permanent facial nerve palsy.

ANALYSES

To conduct the statistical study, we used descriptive and deductive analyses. We employed the Fisher's Exact test for both analyses. All statistical tests were "two-tailed", and significance was set to an α-error <0.05. Statistical differences between groups A and B on the categorical postoperative complications were investigated for deductive purposes.

RESULTS

This study demonstrated the SurgiMend reconstruction to be significantly associated with a lower rate of Frey Syndrome and hypertrophic scar for parotid gland tumor surgery.

CONCLUSION

and relevance: Our study, through sustained and homogeneous follow-up on patients with benign tumors of the parotid gland, associated with a large, representative, and homogeneous sample, allows us to assert the genuineness and reliability of the minor Frey Syndrome and hypertrophic scars rates for benign parotid tumor surgery.

First branchial cleft anomalies in children: long-term outcome in 16 patients

INTRODUCTION

First branchial cleft anomalies (FBCA) are rare congenital head and neck malformations, often subject to incorrect diagnosis and treatment. We present our experience with FBCA, focusing on clinical presentation, diagnosis, perioperative relation to the facial nerve, surgical approach, complications and patient satisfaction.

METHODS

A consecutive cohort of 16 patients undergoing surgical treatment for FBCA between 1999 and 2021 was analyzed. Demographic and clinical information was extracted from their medical records. Additionally 14 patients were interviewed by telephone to assess postoperative outcomes and patient satisfaction using a Likert scale.

RESULTS

Sixteen patients (11 females, 5 males) were surgically treated at an age ranging from 7 months to 13 years. Type I and type II FBCA were evenly distributed. Lesions presented as cysts (n = 4), sinuses (n = 7) or fistulas (n = 5). The main symptoms were swelling, inflammation and discharge. Otologic symptoms were present in 31%. In 80% of patients, magnetic resonance imaging was needed to reach the correct diagnosis. Ten patients (63%) had a history of a surgical attempt in another center before definitive surgical treatment in our center. Complete excision was accomplished in all patients. Postoperative complications included limited Frey syndrome (n = 4), temporary hypertrophic scarring (n = 4), minimal paresis of the marginal mandibular branch of the facial nerve (n = 1) and limited external auditory canal stenosis (n = 1). One patient experienced a recurrence at the level of the external auditory canal, that required minor revision surgery. The average patient satisfaction score was 13.64 out of 15.

CONCLUSION

Thorough clinical examination, awareness of the different entities and awareness of expert head and neck radiological advice are crucial for correct FBCA diagnosis and typing, determining the correct surgical approach. It is crucial that patients diagnosed with FBCA undergo surgery in specialized centers. Despite the challenging surgery and its potential complications, the overall patient satisfaction remains high post- treatment.

Comparative analysis of free SMAS fold flap and ADM in facial depression after parotidectomy

BACKGROUND

This study aimed to analyze the effects of anterior descending mandible (ADM) and free superior mesenteric artery (SMAS) folding flaps on post-parotidectomy facial depression.

METHODS

This retrospective study examined the effects of sex, age, surgical sample size, method, duration, and blood loss on postoperative complications in 65 patients.

RESULTS

No significant differences involving sex, age, or sample size for surgical resection were observed between the two groups. The incidence of Frey syndrome (P = 0.175) and the locations of facial nerve injuries and tumors were not significantly different between the two groups. However, a statistically significant difference was observed in postoperative facial depression between the groups (P = 0.045, P < 0.05). No significant difference was found between facial nerve injury and Frey's sign in subgroup analysis of facial depression deformities. Within the facial depression group, tumor locations were significantly different (P = 0.021, P < 0.05). In the cases of facial depression after partial parotid resection, no significant difference was observed between ADM implantation and SMAS flap placement. A significant difference was noted between the ADM implantation and SMAS flap groups in the total parotidectomy group (P = 0.046 and P < 0.05, respectively).

CONCLUSION

Women are more likely to experience facial depression after parotid surgery. Facial depression is most likely to occur after parotid resection if the tumor is located in the deep lobes of the parotid gland. The use of SMAS flaps can prevent facial depression, and both ADM and SMAS flaps can prevent Frey's syndrome. Partial parotid resection reduces the risk of facial nerve injury and facial depression.

An Extremely Delayed Onset of Frey Syndrome: A Case Report and Literature Review

We report the case of an 80-year-old man with Frey syndrome that developed 30 years postoperatively, which is an exceptionally long period before its occurrence. Sweating and flushing occurred on only the side of his face where the surgery was performed, and he had no other causative abnormalities. Following treatment with botulinum toxin, the patient's symptoms resolved. Extremely early- and late-onset cases do not fit the conventional paradigm of this pathology. Various surgical methods to prevent this syndrome have been explored, but complete prevention has not yet been achieved. These findings suggest that the underlying pathophysiology of Frey syndrome may be more complex than previously recognized.

Frey syndrome after conservative parotidectomy: Importance of closing the remnant parotid parenchyma

BACKGROUND

Frey syndrome (FS) is a typical late complication following parotidectomy. Parotid surgery without proper coverage or reconstruction of exposed parotid parenchyma may contribute to the development of FS. Therefore, this study compared the closure versus the non-closure of exposed parotid parenchyma in the occurrence of FS.

METHODS

This study included 195 patients with parotid lesions who underwent partial or superficial parotidectomy plus closure or non-closure of exposed parotid parenchyma, both with the application of fibrin glue. Two surgical methods of closure and non-closure were allocated to patients without randomization and blinding processes. The primary outcome was FS, and the second outcome was other complication rates.

RESULTS

The closure and non-closure of exposed parotid parenchyma were performed in 102 and 93 patients, respectively. Early postoperative complications occurred with temporary events: transient facial weakness, 32 (16.4%); hematoma, 13 (6.7%); and wound infection, 2 (1.0%), without statistical difference between the two groups (P > 0.1). However, sialocele occurred in the non-closure group (n = 19) more than in the closure group (n = 7) (P = 0.005). In the first postoperative year, decreased sensation and local pain were found in 16 patients (8.2%) and 9 patients (4.6%), respectively, with no statistical difference between the two groups (P > 0.1). FS was found more in the non-closure group (n = 19, 20.4%) than in the closure group (n = 4, 3.9%) (P < 0.001).

CONCLUSION

The closure of exposed parotid parenchyma and covering fascia is preferred over the non-closure to prevent FS.

[Results of a nationwide survey on the treatment of salivary gland diseases in German hospitals]

BACKGROUND

Salivary gland diseases are an important part of the work of ENT physicians in hospitals. The treatment strategies depend, among other things, on the doctrine at the respective location.

OBJECTIVE

The aim of this questionnaire-based study was to assess the current diagnostic workup and therapeutic strategies for salivary gland diseases in German otorhinolaryngology departments.

MATERIALS AND METHODS

A survey was performed using a 25-question online questionnaire sent to all German otorhinolaryngology department directors.

RESULTS

The questionnaire was answered by 92 of 175 otorhinolaryngology departments (52.6%). In the diagnosis of salivary gland tumors, a dominance of sonography and MRI was shown. Fine- and core-needle aspiration were not performed by more than 50% of the clinics. The dominant technique for parotidectomy was under microscopic control (82%). In 99% of clinics, EMG was used during resection of the parotid gland for intraoperative monitoring of the facial nerve. There was a trend towards performing partial parotidectomies (85%), lateral parotidectomies (70%), and extracapsular dissections (57%) for benign tumors of the parotid gland. The treatment concepts for malignant tumors were inconsistent.

CONCLUSION

In particular, the treatment strategy and extent of surgery for benign and malignant salivary gland tumors differed depending on location. The choice of palliative (drug) therapy was also diverse. Prospective multicenter studies could help to develop evidence-based treatment strategies.

Electrocautery, Harmonic, and Thunderbeat Instruments in Parotid Surgery: A Retrospective Comparative Study

The aim of this retrospective study has been to compare the surgical outcomes of patients undergoing superficial parotidectomy with three different instruments: bipolar electrocautery, ultrasound, and mixed energy instruments. The clinical records of 102 patients who had undergone superficial parotidectomy for benign tumors between January 2016 and April 2022 were considered. Based on the tool used during the surgery, the patients were divided into three study groups: classic electrocautery hemostasis group (CH group), ultrasonic instrument group (HA group), and combined energy instrument group (TB group). The duration of surgery, the total post-operative drainage volume, and the intra-operative blood loss were significantly higher in the CH group compared to the HA and the TB group, while the differences were not significant between the latter two groups. Facial nerve weakness was detected in 45.9% of the CH group, 12.5% of the HA group, and 21.2% of the TB group. The rate of facial nerve dysfunction in the CH group was significantly higher than in the HA group (0.011). In the patients who experienced post-operative facial nerve dysfunction, the recovery time was significantly shorter in the HA group compared to the CH and the TB group. The HA and TB groups have demonstrated comparable and significantly better surgical outcomes than bipolar electrocautery. Ultrasound instruments have been shown to cause, in comparison with the other techniques, a lower rate of temporary facial nerve dysfunction and, if this is present, lead to a faster spontaneous recovery time.

Surgical interventions for management of benign parotid tumors: A systematic review and network meta-analysis

The impact of the extent of parotid surgery on postoperative complications has long been considered a topic of controversy. The aim of the current network meta-analysis (NMA) is to answer the following questions: (1) Does the extent of surgical resection of benign parotid tumors increase the risk of postoperative complications? (2) What is the best surgical intervention for treatment of benign parotid tumors that can provide an acceptable balance between tumor recurrence rate and other postoperative complications? A comprehensive search on PubMed, Embase, Scopus, and Cochrane library was conducted to identify the eligible studies. The outcome was the incidence of tumor recurrence, facial nerve weakness (temporary [TFW] or permanent [PFP]), Frey's syndrome (FS), sialocele, and salivary fistula. The Bayesian network meta-analysis (NMA) accompanied by a random effect model and 95% credible intervals (CrI) were calculated using the GeMTC R package. Forty-four studies with a total of 7841 participants were included in the current NMA comparing five surgical interventions, namely enucleation, extracapsular dissection (ECD), partial superficial parotidectomy (PSP), superficial parotidectomy (SP), and total parotidectomy (TP). Enucleation showed the highest recurrence rate compared to ECD, SPS, SP, and TP. No statistical differences were observed concerning the recurrence rate when ECD, PSP, SP, and TP were compared together. There was an increased incidence of TFW and FS with the increase in the extent of parotid resection, while no significant difference was found when comparing enucleation with ECD and PSP. SP showed the highest incidence of PFP, and salivary fistula compared to ECD, PSP, and TP. The tumor recurrence rates in enucleation, ECD, PSP, SP, and TP were 14.3%, 3.6%, 3.7%, 2.8%, and 1.4%, respectively. The current NMA demonstrated that the risk of TFW and FS increases with the increase in the extent of parotid resection and that ECD and PSP can be considered the treatment of choice for benign parotid tumors, as both provide an acceptable balance between the incidence of tumor recurrence and facial nerve dysfunction.