Case-tailored indicated extracapsular dissection versus "one-size-fits-all" nerve dissection: Has the bet been won?

OBJECTIVE

The aim of the study was to trace the development of surgical therapy in a large cohort, examine its changes at one single institution that has been specializing in salivary gland pathologies over the last 22 years, and to determine the extent to which a possible shift in the surgical therapy of parotid benign tumors towards less radical methods was correlated with a change in the incidence of facial palsy and Frey's syndrome.

STUDY DESIGN

Retrospective clinical study.

METHODS

A retrospective evaluation of the records of all patients treated for benign parotid tumors at a tertiary referral center between 2000 and 2022 was carried out. Surgical methods were classified into four groups: extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy and complete parotidectomy.

RESULTS

A total of 4037 patients were included in the study. Our analysis demonstrated an increase in the total number of parotidectomies for benign lesions from 71 (2000) to 298 (2022), mostly due to the increase in extracapsular dissections (from 9 to 212). The increased performance of less radical surgery was associated with a significantly decreased incidence of perioperative complications.

CONCLUSIONS

Our study showed that the increased performance of less radical surgery was associated with better functional outcomes over the years.

Surgical management of Warthin tumor: long-term follow-up of 224 patients from 2002 to 2018

PURPOSE

Warthin tumors (WT) are the second most common benign parotid gland neoplasms. They can occur as synchronous or metachronous lesions in 6-10% of cases. This study aims to compare the complication rate in 224 patients who underwent extracapsular dissection (ECD) or superficial parotidectomy (SP) for the treatment of a WT.

METHODS

This retrospective study was conducted at the Department of Maxillo-Facial Surgery at the University of Naples "Federico II" from February 2002 to December 2018 on a group of patients who underwent surgical treatment for WT. The type of surgical technique was chosen based on Quer's classification. The complications evaluated were facial nerve palsy, hematoma, Frey's syndrome, and bleeding.

RESULTS

A total of 224 patients treated from 2002 to 2018 for Warthin tumor were included in the study. Two hundred elven had solitary tumors (94.1%) and 13 had multicentric lesions (5.8%), of which 9 cases presented synchronous lesions and 4 cases presented metachronous lesions. Extracapsular dissection (ECD) was performed in 130 patients (58.3% of cases) and superficial parotidectomy (SP) in the other 94 (41.7% of cases).

CONCLUSIONS

We consider both surgical techniques as valid. In our opinion, it is essential to study each case based on Quer's Classification to obtain the best surgical outcome. Based on a lower observed rate of complications such as facial nerve palsy, Frey's syndrome, and bleeding, ECD seems to be the best option for the surgical treatment of Quer Class I lesions.

Extracapsular dissection via single cervical incision for parotid pleomorphic adenoma

OBJECTIVES

Surgical management of parotid pleomorphic adenoma ranges from total parotidectomy to extracapsular dissection (ECD). Minimalistic techniques aim to preserve function and minimize the rate of recurrence. This study assesses functional, aesthetic, and disease control outcomes post-ECD through a sole transverse cervical incision for parotid pleomorphic adenoma.

MATERIALS AND METHODS

This longitudinal analysis enrolled 36 consecutive patients with pleomorphic adenoma who underwent ECD via a single cervical incision. Complications, satisfaction, salivary function, and tumor recurrence were evaluated. Salivary gland function was assessed using scintigraphy at 6 months post-surgery.

RESULTS

Tumors occurred in superficial (83%) or deep (17%) parotid inferior parts according to the European Salivary Gland Society level classification. The median tumor size was 2.8 cm (1.8-6.0 cm); the median operation time was 42 min (30-65 min). No tumor spillage or facial nerve injuries occurred. Facial nerve paralysis was only temporary in two (6%) patients, with minimal other complications. Operated parotid gland function matched the unoperated side. No recurrence was found during the median follow-up of 44 months (24-60 months).

CONCLUSIONS

ECD via a single transverse cervical incision is a safe approach for benign parotid tumors, yielding excellent functional and disease control outcomes.

CLINICAL RELEVANCE

These findings can provide clinically meaningful minimally invasive recommendations to treat pleomorphic adenoma with minimal complications.

Function-preserving surgery via single transverse cervical incision for Warthin's tumor in the parotid gland

BACKGROUND

This study evaluated functional and disease control outcomes after gland-preserving surgery via a single transverse cervical incision for Warthin's tumor of the parotid gland.

METHODS

One-hundred eleven patients with Warthin's tumor underwent the preservation of most normal parotid tissues and the facial nerve combined with the en-bloc resection of tumors. Postoperative complications, subjective satisfaction, salivary function, and metachronous tumor were assessed in each patient.

RESULTS

No patients had an extension to modified Blair or periauricular incision with the median operation time of 32 min. Temporary and permanent paralysis of the facial nerve was 5 (4.0%) and none of 125 tumor resection sides, respectively. Postoperative complications were minimal. The secretory functions between the affected and unaffected glands did not differ. One patient had metachronous tumor for a median follow-up of 72 months.

CONCLUSION

Functional gland-preserving surgery via single transverse cervical incision can safely treat Warthin's tumor in the parotid gland.

Current Trends and Controversies in the Management of Warthin Tumor of the Parotid Gland

Purpose: To review the current options in the management of Warthin tumors (WTs) and to propose a working management protocol. Methods: A systematic literature search was conducted using PubMed and ScienceDirect database. A total of 141 publications were selected and have been included in this review. Publications were selected based on relevance, scientific evidence, and actuality. Results: The importance of parotid WTs is increasing due to its rising incidence in many countries, becoming the most frequently encountered benign parotid tumor in certain parts of the world. In the past, all WTs were treated with surgery, but because of their slow growth rate, often minimal clinical symptoms, and the advanced age of many patients, active observation has gradually become more widely used. In order to decide on active surveillance, the diagnosis of WT must be reliable, and clinical, imaging, and cytological data should be concordant. There are four clear indications for upfront surgery: uncertain diagnosis; cosmetic problems; clinical complaints, such as pain, ulceration, or recurrent infection; and the patient’s wish to have the tumor removed. In the remaining cases, surgery can be elective. Active surveillance is often suggested as the first approach, with surgery being considered if the tumor progresses and/or causes clinical complaints. The extent of surgery is another controversial topic, and the current trend is to minimize the resection using partial parotidectomies and extracapsular dissections when possible. Recently, non-surgical options such as microwave ablation, radiofrequency ablation, and ultrasound-guided ethanol sclerotherapy have been proposed for selected cases. Conclusions: The management of WT is gradually shifting from superficial or total parotidectomy to more conservative approaches, with more limited resections, and to active surveillance in an increasing number of patients. Additionally, non-surgical treatments are emerging, but their role needs to be defined in future studies.

Investigation of Sonographic Criteria for Reliable Identification of T1-T2 Low-Grade Malignant Tumors of the Parotid Gland

The aim of this study was to investigate sonographic findings of low-grade malignant tumors of the parotid gland. The sonographic findings of all patients treated for T1-T2 low-grade carcinomas of the parotid gland between 2003 and 2018 were retrospectively examined and compared with those of patients with pleomorphic adenomas for the following parameters: definition of tumor margins, echotexture, echogenicity, shape and vascularization. Statistical analysis was performed using the χ² test. A p value of <0.05 was considered statistically significant. A total of 310 patients (62 with T1-T2 low-grade malignant tumors, 248 with pleomorphic adenomas) were evaluated. Our analysis detected a statistically significant difference in the definition of margins, echotexture, echogenicity and shape. Furthermore, we could detect a specific pattern (anechoic islets in a small hypoechoic lesion with distal enhancement) appearing far more frequently in low-grade malignant lesions. It seems that there is still potential to reduce the incidence of the false working hypothesis "benign lesion" on imaging of low-grade malignant tumors.

Change in Warthin's tumor incidence: a 20-year joinpoint trend analysis

PURPOSE

The incidence of Warthin's tumor (WT) has increased worldwide. In this study, we aimed to evaluate the incidence of WT in our hospital, which provides health care for an extremely large population.

METHODS

We retrospectively evaluated 573 patients, comprising 345 males and 228 females, who all experienced parotid tumor for the past 20 years. Patients with WT that were operated in the last 20 years were evaluated according to the number of patients per year to determine the annual WT increase trend.

RESULTS

In the distribution of WT over the years of surgery, the ratio of WT to all tumors irregularly changed. Furthermore, the total number of parotidectomies per year increased in time. We investigated whether WT had any increasing trend over the years. The annual percentage change (APC) of WT was calculated, and according to the segmented regression analysis, the APC was insignificant (APC = 4.3, 95% CI = - 3.6-12.9, P = 0.300).

CONCLUSION

The incidence of WT has increased across the world. However, in our study, no significant APC was observed according to the segmented regression analysis.

Two case reports of synchronous unilateral pleomorphic adenoma and cystadenolymphoma of the parotid gland with literature review

Background: Synchronous unilateral tumors in the parotid glands account for less than 5-10% of all salivary gland neoplasms. Mostly these are cystadenolymphomas, but tumors of different histological types can be found as well. In these cases it is often pleomorphic adenoma in combination with cystadenolymphoma. Ultrasound is the first choice imaging modality. Case report: We present two patients with two simultaneous tumors in a unilateral parotid gland. In each case, B-mode ultrasound showed two hypoechoic masses, one of which was predominantly cystic. The subsequent use of Virtual Touch Imaging Quantification (VTIQ) showed tumors of elastic tissue. After a parotidectomy, both cases were diagnosed with pleomorphic adenoma combined with cystadenolymphoma. Conclusion: The combination of B-mode ultrasound and VTIQ is an important diagnostic modality and may improve diagnostic accuracy to differentiate between benign and malignant lesions. Every clinician should be aware of the co-existence of different histological types of tumors in unilateral salivary glands.

Background: Synchronous unilateral tumors in the parotid glands account for less than 5–10% of all salivary gland neoplasms. Mostly these are cystadenolymphomas, but tumors of different histological types can be found as well. In these cases it is often pleomorphic adenoma in combination with cystadenolymphoma. Ultrasound is the first choice imaging modality. Case report: We present two patients with two simultaneous tumors in a unilateral parotid gland. In each case, B-mode ultrasound showed two hypoechoic masses, one of which was predominantly cystic. The subsequent use of Virtual Touch Imaging Quantification (VTIQ) showed tumors of elastic tissue. After a parotidectomy, both cases were diagnosed with pleomorphic adenoma combined with cystadenolymphoma. Conclusion: The combination of B-mode ultrasound and VTIQ is an important diagnostic modality and may improve diagnostic accuracy to differentiate between benign and malignant lesions. Every clinician should be aware of the co-existence of different histological types of tumors in unilateral salivary glands.

Investigation of the surgical strategies for unilateral multifocal cystadenolymphomas of the parotid gland

OBJECTIVES

The aim of the study was to compare multifocal extracapsular dissection with complete parotidectomy in the treatment of unilateral multifocal cystadenolymphomas of the parotid gland.

MATERIALS AND METHODS

The records from all patients treated for unilateral multifocal cystadenolymphomas of the parotid gland at a tertiary referral center between 2000 and 2016 were retrospectively analyzed.

RESULTS

203 patients were included in the study. 96 patients were managed by multifocal extracapsular dissection, 107 patients underwent complete parotidectomy. Metachronous tumors were detected in 7 cases (3.4%) with a significant difference in the occurrence rate between multifocal extracapsular dissection (7/96, 7.3%) and complete parotidectomy (0/107, 0%) (p = 0.004). Permanent facial palsy was significantly more common after complete parotidectomy (21/107, 19.6%) than multifocal extracapsular dissection (2/96, 2.1%) (p = 0.000).

CONCLUSIONS

The functional benefit of multifocal extracapsular dissection was counterbalanced by the advantage of complete parotidectomy, in terms of recurrences. Extracapsular dissection is at its limit in cases of multifocal cystadenolymphomas and the indication for it should be thoroughly verified in each and every case.