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

A retrospective comparison of mid-cheek tumor dissection between endoscopically assisted and conventional approach

BACKGROUND

Surgery for tumors in the mid-cheek area are challenging. Endoscopic-assisted dissection of benign mid-cheek tumors is gradually being reported. This study evaluated the indications, advantages and disadvantages of endoscopically assisted mid-cheek benign tumor resection using a single preauricular or transoral incision and compared it with the conventional approach.

METHODS

Fifty-four patients with benign mid-cheek tumors could be divided into three groups: a conventional (20 patients) parotidectomy access surgery group, another two endoscope-assisted tumor dissections groups through a single preauricular incision (17 patients) or transoral incision (17 patients). Their surgical approaches were introduced, and the tumor long-axis length, incision length, operative time, estimated intraoperative bleeding, postoperative drainage amount and time, aesthetic satisfaction, perioperative complications, and follow-up were recorded and analyzed.

RESULTS

The tumor long-axis lengths were comparable between the groups, and all surgical procedures were completed as planned. The endoscopic procedure group improved the incision size, intraoperative blood loss, drainage, perioperative complications, and cosmetic satisfaction. Meanwhile, aesthetic pleasure is highest with the transoral incision. No tumor recurrence was found during the 1-54-month of follow-up.

CONCLUSION

Endoscopic-assisted preauricular or transoral incision for dissecting mid-cheek benign tumors is more aesthetic and minimally invasive than conventional surgical approaches with available results, reducing complications, narrowing the surgical incision, and obtaining satisfactory aesthetic results.

Trends in the Extent of Surgical Management for Low-Grade Parotid Malignancies: A SEER Analysis

OBJECTIVE

Low-grade parotid malignancies have high overall survival rates; however, controversy remains about the appropriate extent of surgery. We aim to explore the trends in the extent of parotidectomy performed over time in low-grade parotid malignancies in the United States, with a hypothesis that there has been a trend towards less aggressive surgery.

STUDY DESIGN

Retrospective cohort study of all low-grade (grade I) acinic cell carcinoma (ACC) and mucoepidermoid carcinoma (MEC) in the Surveillance, Epidemiology, and End Results (SEER) from 2004 to 2020.

SETTING

Geographic areas served by SEER.

METHODS

Trends were assessed using Cochran-Armitage tests and logistic regression; Kaplan-Meier survival curves were used to analyze overall and cancer-specific survival, and chi-square tests were used to analyze patient characteristics.

RESULTS

In total, 1288 patients were identified (916 MEC; 372 ACC). Most patients (n = 772, 60%) were non-Hispanic white, with an average age of 50.6 years and had a slight female predominance (1.58:1). Most of the cohort presented with tumor stage T1 or T2 (84%), N0 (90.1%), and M0 (96.9%). Treatment with total parotidectomy decreased significantly (34.6 vs 17.7%, P = .02) whereas sacrificing the facial nerve (FN) slightly decreased (20 vs 15.7%, P = .1). A significant increase in N0 patients (71%-94%, P < .0001) was observed, whereas T staging remained stable (61%-64%, P = .3). Overall, both ACC and MEC had excellent cancer-specific survival.

CONCLUSION

Over the last 17 years, there has been a significant de-escalation in the extent of parotidectomy for low-grade parotid malignancy in the United States.

Safety and Efficacy of Radiofrequency Ablation for Superficial Parotid Pleomorphic Adenoma

OBJECTIVE

To retrospectively compare the safety and efficacy of ultrasound-guided radiofrequency ablation (RFA) with parotidectomy for superficial pleomorphic adenoma (PA).

MATERIALS AND METHODS

From March 2022 to October 2023, 88 patients diagnosed with superficial parotid PA underwent either RFA (n = 12; mean age, 47.1 years) or parotidectomy (n = 76; mean age, 47.8 years). Patients in the RFA group were matched to those in the surgery group in a 1:1 ratio using propensity scores based on age, sex, tumor volume, diameter, location, and comorbidities. Ultrasound characteristics, cosmetic scores (0-4), numerical rating scale scores (0-10), and complications were assessed before the procedures and at 1-, 3-, and 6-month follow-ups. Outcomes were compared between baseline and follow-up in the RFA group and between the RFA and surgery groups.

RESULTS

In the RFA group, significant reductions in tumor volume were observed between baseline (median, 2.02 cm³) and the 1-month follow-up (median, 1.21 cm³; P = 0.015), between the 1-month and 3-month follow-ups (median, 0.53 cm³; P = 0.002), and between the 3- and 6-month follow-ups (median, 0.23 cm³; P = 0.003). The volume reduction ratios at 1, 3, and 6 months were 39.7%, 79.9%, and 88.0%, respectively. The cosmetic score was significantly lower at 3- and 6-month follow-up compared to baseline (median 1 and 1 vs. 4, P = 0.04). The numerical rating scale scores did not differ significantly from baseline throughout follow-up. In the propensity score-matched analysis (12 patients per group), RFA was associated with a shorter median procedure time (61.5 vs. 253.3 minutes; P < 0.001), shorter hospital stay (0 vs. 4 days; P < 0.001), and lower cost (1859.9 vs. 3512.4 USD; P < 0.001) than parotidectomy, with no significant difference in overall complication rates (33.3% [4/12] vs. 41.7% [5/12]; P = 1.000).

CONCLUSION

RFA may be a safe and effective alternative to surgery for superficial parotid PA, offering a shorter median procedure time, shorter hospital stay, and lower costs.

Active Surveillance for Pleomorphic Adenomas of the Parotid-Tumor Growth Rate, Potential Malignancy, and Surgical Sequalae

OBJECTIVE

The outcomes of active surveillance (AS) for pleomorphic adenomas (PA) as an alternative to upfront parotidectomy have not been previously documented in the literature. This cohort study aims to assess the safety and feasibility of AS for parotid gland PA.

METHODS

All patients with of previously untreated PA managed between 1990 and 2015 were reviewed. Patients who underwent AS for a minimum of 1 year from the initial consultation were identified. Patient demographics, the reason for AS, tumor growth rate, indication for surgery in those patients eventually operated, final pathology, and surgical sequelae were analyzed.

RESULTS

During the study period, 610 patients with primary PA were treated in our institution. Of whom, 14 (2.3%) underwent AS for a period between 1 and 10 years with a median of 3.73 years (interquartile range [IQR] 1.3-4.9). Patient comorbidities were the most common reason for opting for AS (n = 6, 43%), followed by patients' preference to delay surgery (n = 4, 29%) and older age (n = 2, 14%). The median growth rate was 0.58 mm/year (IQR 0.04, 3.8, range -5.01 to 4.98 mm/year). In patients who eventually underwent parotidectomy (n = 10, 71.4%), the most common reason for intervention was tumor growth (8/10, 80%). Two patients had postsurgical mild transient facial nerve paresis with full recovery, and no carcinomas were discovered on final pathology.

CONCLUSION

In this selected cohort of patients with PA, the tumor growth rate was lower than traditionally believed. Patients who eventually underwent surgery did not suffer from serious complications and there was no evidence of clinical or pathological malignancy.

Postoperative pain after parotid surgery-comparison between superficial/total parotidectomy and extracapsular dissection: a prospective observational study

PURPOSE

To evaluate postoperative pain and discomfort after parotid surgery with regard to different surgical approaches.

METHODS

This clinical study was carried out at a single tertiary referral center (2021-2022) and included 2 groups of adult patients (mean age 56.6 ± 12.7 vs. 53.4 ± 14.1 years) following elective parotid surgery due to a parotid tumor of any entity. The first group (SP/TP group) consisted of 31 patients after superficial parotidectomy (SP) or total parotidectomy (TP) (n = 31). The second group (ECD group) included all patients who had undergone extracapsular dissection (ECD) (n = 51). Primary endpoints comprised pain on ambulation as well as maximum and minimum pain (NRS 0-10) on the first three postoperative days (PODs). A neuropathic pain component (evaluated on POD 1 and 3), the analgesic score (collected from the patient file on POD 1-3), treatment-related side-effects/pain-associated impairments, and patient satisfaction (all measured on the 1st POD) were defined as secondary endpoints. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire and the painDETECT® questionnaire. Comparisons were performed using independent t tests, Wilcoxon tests, and χ2 tests, and the respective effect sizes were calculated.

RESULTS

Looking at the first postoperative day, patients of both groups (SP/TP vs. ECD) reported comparable pain on ambulation (2.8 ± 2.0 vs. 2.6 ± 1.8; p = 0.628, r = 0.063), maximum (3.5 ± 2.2 vs. 3.5 ± 2.3; p = 0.992, r = 0.002) and minimum pain (1.1 ± 1.04 vs. 1.0 ± 1.2; p = 0.206, r = 0.157). Furthermore, there were no significant differences in pain-related restrictions or pain medication requirement. The patients in both groups were equally satisfied with their pain therapy (p = 0.282, R = 0.135). The sum score of the painDETECT® questionnaire delivered clearly negative (< 12) results on average (POD1: 6.81; POD3: 6.59); no significant difference between the groups was found (p = 0.991, R2 < .001).

CONCLUSION

Neither surgical technique on the parotid gland was significantly superior to the other in terms of postoperative pain perception. Overall, postoperative pain can be classified as mild to moderate following parotid surgery. A neuropathic pain component could be excluded for the acute postoperative phase.

TRIAL REGISTRATION

The study was registered in the German Registry for Clinical Studies (DRKS) (application No.: DRKS00016520).

Intraparotid Sentinel Lymph Node Dissection for Melanoma: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical management of head and neck cutaneous melanoma (HNCM) has evolved tremendously since sentinel lymph node biopsy (SLNB) has become the prominent tool of prognosis and staging. This meta-analysis aimed to evaluate the safety and efficiency of intraparotid SLNB compared with a more extensive surgery of superficial parotidectomy (SP).

METHODS

The electronic database of PubMed and Scopus were searched for publications until 10 March 2022. In addition, the study included data of patients from our institution who underwent cherry-picking procedures. Pooled estimates were calculated using the random-effects model. Heterogeneity was calculated using the I2 test.

RESULTS

The pooled result regarding the rate of SLNB excision success was 97 % (95 % confidence interval [CI], 0.95-0.99; p < 0.0001), and the pooled probability of a positive SLNB result was 16 % (95 % CI 0.12-0.20; p < 0.0001). Failure of SLNB had pooled results of 4 % (95 % CI 0.02-0.06; p < 0.0009). For SP, no study examining N0 HNCM patients has met the authors' inclusion criteria. Cherry-picking SLNB had temporary and permanent facial nerve paralysis relative risks (RRs) of 0.12 (95 % CI 0.06-0.27; p < 0.0001) and 0.46 (95 % CI 0.17-1.22; p < 0.0001), respectively, compared with historical data from four weighted meta-analyses of SP.

CONCLUSIONS

The data from this study suggest that intraparotid SLNB performed for N0 HNCM patients is a safe and reliable procedure, with very low complication rates. Failure of the procedure did not exceed 4 %. Therefore, intraparotid SLNB may be superior to an extensive surgery such as SP and should be examined in future prospective trials.

Extracapsular dissection versus total excision for benign submandibular gland tumors

INTRODUCTION

Benign submandibular gland tumors pose challenges in balancing treatment effectiveness and preserving gland function. This study aimed to compare gland-preserving surgery, extracapsular dissection (ECD), with total excision in managing these tumors, focusing on function preservation and recurrence rate.

METHODS

Fifty consecutive patients with treatment-naïve benign submandibular gland tumors were alternatively allocated to receive ECD (n = 25) or total excision (n = 25) without randomization procedures. Intraoperative findings, postsurgical complications, subjective satisfaction, and gland function were assessed. Follow-up data were collected for a median duration of 55 months (24-80 months) to monitor recurrences.

RESULTS

ECD demonstrated significant advantages, including shorter operation time, reduced bleeding, and preservation of the facial artery and vein (P < 0.05). Both groups exhibited acceptable postsurgical pain and taste sensations. Complications were minimal and similar between the two groups. ECD resulted in superior facial contour satisfaction (P = 0.030) and preserved gland function, as evidenced by salivary scintigraphy. No recurrences were observed in either group during the follow-up period.

CONCLUSIONS

ECD is a practical approach for benign submandibular gland tumors, offering favorable functional outcomes, reduced surgical morbidity, shorter operation times, and improved cosmetic results.

Ultrasound-guided percutaneous thermal ablation of parotid tumors: experience from two-centers

Objective: To evaluate the efficacy and feasibility of ultrasound-guided percutaneous thermal ablation (TA) for treating benign parotid tumors.Methods: Patients with benign parotid tumors who underwent ultrasound-guided microwave ablation (MWA) or radiofrequency ablation (RFA) between January 2020 and March 2023 were included in this retrospective study. Change in tumor size (maximum diameter, tumor volume(V), volume reduction rate (VRR)) and cosmetic score (CS) were evaluated during a one-year follow-up period. We also recorded the incidence of any complications associated with TA.Results: A total of 23 patients (13 males and 10 females; median age 65 years, range 5-91 years) were included. The mean VRR at 1, 3, 6, and 12 months after TA was 37.03%±10.23%, 56.52%±8.76%, 82.28%±7.89%, and 89.39%±6.45%, respectively. Mean CS also changed from 3.39 ± 0.66 to 1.75 ± 0.93 (p < 0.001) by the end of follow-up time. Subgroup analysis showed that tumors with smaller initial maximum diameter had a faster CS reduction rate than those with larger initial diameter. The incidence of facial nerve dysfunction was 8.70%.Conclusion: Ultrasound-guided percutaneous TA is an effective and safe treatment option for patients with benign parotid tumors.

Minimally invasive retroauricular approach parotidectomy: A pictorial essay

The surgical approach to a parotid neoplasm has traditionally been taught through a modified-Blair incision. This approach results in a visible scar in the preauricular, retromandibular, and upper neck skin. Various modifications have been undertaken which aim to improve cosmesis either by decreasing overall incision length and/or relocation of the incision to the hairline via what is commonly described as a "facelift approach". We describe a novel minimally invasive parotidectomy approach which utilizes a single retroauricular incision. This approach eliminates both the preauricular scar as well as the extended incision in the hairline and additional skin flap elevation which accompanies it. Sixteen patients underwent parotidectomy using this minimally invasive incision and the excellent clinical outcomes are reviewed. The minimally invasive retroauricular approach to parotidectomy provides excellent exposure with no visible incision/scar in appropriately selected patients.

Sialocele formation after partial parotidectomy: Dependent on remnant parotid exposure

BACKGROUND

This study compared the complete closure versus the exposure of remnant parotid parenchyma in sialocele formation.

METHODS

This study included 151 patients with benign parotid lesions who underwent partial parotidectomy plus the complete closure or exposure of remnant parotid parenchyma. Two surgical methods of closed or exposed parenchyma were alternatively allocated to consecutive patients without randomization and blinding processes.

RESULTS

Complete closure and exposure of the remnant parotid parenchyma were performed in 81 and 70 patients. Early postoperative complications occurred with temporary events: transient facial weakness, 24 (16%); hematoma, 9 (6%); wound infection, 1 (0.7%) without statistical difference between the two groups (p > 0.1). Postoperative sialocele was more frequently found in the exposure group (n = 15) than the closure group (n = 4; p = 0.003).

CONCLUSIONS

The complete closure of remnant parotid parenchyma is preferred over the exposure of injured parenchymal parenchyma to prevent postparotidectomy sialocele.

[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.

Comparative analysis of benign and malignant parotid gland tumors: A retrospective study of 992 patients

OBJECTIVE

We analyzed and compared the clinical characteristics of benign and malignant parotid gland tumors.

PATIENTS AND METHODS

A total of 992 patients who underwent surgical treatment for parotid gland tumors from January 2010 to December 2020 were included in this study. This study population was subdivided into benign (n = 812, 81.9 %) and malignant parotid gland tumors (n = 180, 18.1 %).

RESULTS

Pleomorphic adenoma is the most common benign tumor and mucoepidermoid carcinoma is the most common malignant tumor. The patients with malignant parotid gland tumors were older than the patients with benign lesions. The duration of symptoms was longer in patients with benign parotid gland tumors compared to those with malignant lesions. The size of the malignant tumors was larger than that of the benign lesions. Preoperative fine-needle aspiration cytology had a diagnostic sensitivity of 50.3 %, diagnostic specificity of 98.7 %, a positive predictive value of 89.5 %, a negative predictive value of 89.9 %, and accuracy of 89.9 % for diagnosing malignant parotid gland tumors. For benign parotid gland tumors, superficial parotidectomy was most frequently performed, and for malignant parotid gland tumors, total parotidectomy was most frequently performed. Facial palsy was observed in 19.4 % of the patients with malignant parotid gland tumors compared to 5.4 % of those with benign tumors.

CONCLUSION

The clinical features of benign and malignant parotid gland tumors showed differences in age, symptoms, duration of symptoms, size and site of the parotid tumors, surgical procedures, and postoperative facial nerve palsy.

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.

Superficial versus total parotidectomy for recurrent pleomorphic adenoma in the parotid gland

Recurrent pleomorphic adenoma (RPA) is a challenging disease because of difficulty in reoperation, a high rate of postoperative facial palsy, and potential malignant transformation. The optimal management of RPA is still arguable regarding the surgical extent and the necessity of radiotherapy. Therefore, this study compared the complication and re-recurrence rates of superficial versus total parotidectomy in a prospective cohort of 29 patients with RPA. Two surgical techniques were allocated to consecutive patients without randomization and blinding processes. Total parotidectomy was applied to lesions in deep or both lobes. Most early and late complication rates were statistically comparable between the two groups (P > 0.05). Transient and permanent facial nerve paralysis frequently occurred in 55 % and 14 % of all cases, respectively, without statistical difference between the two groups (P > 0.5). Only one patient (3 %) had re-recurrence after superficial parotidectomy during the mean follow-up of 89 months. Superficial or total parotidectomy is recommended to reduce the risk of further recurrence in patients with RPA.

Extracapsular dissection by the sternocleidomastoid muscle-parotid space approach reduces the risks of postparotidectomy sialocele and salivary fistula

BACKGROUND

Postoperative sialoceles and fistulas are frequent surgical complications of parotid tumor resection. Extracapsular dissection by the sternocleidomastoid muscle-parotid space approach (ECD-SMPSA) is a minimally invasive technique. To our knowledge, the characteristics of sialoceles and fistulas secondary to ECD-SMPSA have not been reported.

METHODS

This prospective study enrolled 52 patients who underwent ECD-SMPSA without sialocele/fistula prevention measures. Postoperative sialoceles and fistulas were evaluated during 2 months of follow-up.

RESULTS

Among the 52 patients, only one male patient developed a mild sialocele. No salivary fistulas occurred. The overall rate of sialocele/fistula formation was 1.92%.

CONCLUSIONS

When treating clinically benign tumors that involve the sternocleidomastoid muscle-parotid space, ECD-SMPSA may prevent postoperative formation of sialoceles and salivary fistulas.

Gland-preserving surgery of benign parotid tumours via postauricular sulcus incision: Is it safe and effective with the scarless incision?

Gland-preserving surgery has been introduced to reduce the complications of conventional parotidectomy that requires removal of total superficial or entire parotid gland along with the tumour. Several cosmetic incisions have also been developed along with conservative parotid surgery involving partial dissection of the facial nerve and gland. The incision length in the cosmetic approaches is gradually shortened from facelift to periauricular incision, and endoscopic parotidectomy techniques emerged. A more functional approach via postauricular sulcus incision was also introduced to remove benign parotid tumours with high cosmetic satisfaction and oncological safety. Therefore, this article presents the surgical procedures, potential indications, pros and cons of the postauricular sulcus approach.