Prophylaxis against Frey's syndrome in parotid surgery

Evaluation of the effectiveness of superficial parotidectomy and partial superficial parotidectomy for benign parotid tumours: a meta-analysis

OBJECTIVE

To quantify the results of superficial parotidectomy (SP) and partial SP (PSP) for benign parotid tumours using a systematic evaluation method.

METHODS

A systematic search of English and Chinese databases (PubMed, Web of Science, Cochrane Library, China Knowledge Network, Wanfang and Vipshop) was conducted to include studies comparing the treatment outcomes of SP with PSP.

RESULTS

Twenty-three qualified, high-quality studies involving 2844 patients were included in this study. The results of this study showed that compared to the SP surgical approach, the PSP surgical approach reduced the occurrence of temporary facial palsy (OR = 0.33; 95% confidence interval [CI] 0.26-0.41), permanent facial palsy (OR = 0.28; 95% CI 0.16-0.52) and Frey syndrome (OR = 0.36; 95% CI 0.23-0.56) in patients after surgery, and the surgery operative time was reduced by approximately 27.35 min (95% CI - 39.66, - 15.04). However, the effects of PSP versus SP on salivary fistula (OR = 0.70; 95% CI 0.40-1.24), sialocele (OR = 1.48; 95% CI 0.78-2.83), haematoma (OR = 0.34; 95% CI 0.11-1.01) and tumour recurrence rate (OR = 1.41; 95% CI 0.48-4.20) were not statistically significant.

CONCLUSION

Compared with SP, PSP has a lower postoperative complication rate and significantly shorter operative time, suggesting that it could be used as an alternative to SP in the treatment of benign parotid tumours with the right indications.

Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE/HYPOTHESIS

To define the best surgical technique able to reduce Frey syndrome (FS) incidence after parotidectomy.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were the incidence of subjective (clinical) and objective (positive starch-iodine test result) FS, respectively.

RESULTS

A total of 3830 patients with a median age of 50.35 years (n = 2323; IQR 44.25-54.18) were included for six interventions [temporoparietal fascia (TPFF), free fat graft (FFG), acellular dermal matrix (ADM), sternocleidomastoid muscle (SCM) flap, and superficial musculoaponeurotic system (SMAS) flap]. If compared to no treatment, the greatest reduction of subjective (clinical) FS incidence was measured for the TPFF (OR: 0.07, CI: 0.004-0.57), the ADM (OR: 0.09, CI: 0.02-0.35), and the FFG (OR: 0.11, CI: 0.03-0.42) techniques. However, a significant difference was measured also for the SCM flap (OR: 0.38, CI: 0.18-0.73) and for the SMAS flap (OR: 0.42, CI: 0.19-0.97). All treatments showed a significant reduction of the objective FS incidence if compared to no treatment (FFG, OR: 0.06, CI: 0.002-0.62; TPFF, OR: 0.07, CI: 0.01-0.33; ADM, OR: 0.11, CI: 0.03-0.44; SMAS, OR: 0.36, CI: 0.17-0.71; SCM, OR: 0.40, CI: 0.19-0.74).

CONCLUSIONS

TPFF, ADM, and FFG seem to be the best treatment strategies to prevent FS after parotidectomy. Further randomized controlled trials comparing these techniques should be conducted to define specific indications. Laryngoscope, 131:1761-1768, 2021.

Vascularised fatty tissue: its role in prevention of the symptoms of Frey syndrome after parotidectomy

We studied 37 consecutive patients who had parotidectomies between 2008 and 2017 and who had vascular fat flaps inserted to replace the excised parotid tissue and prevent Frey syndrome. They were followed up for 1-9 years to check for the relevant symptoms. We studied 17 female and 20 male patients, mean age 52 (range 19-78) years. The flaps took a maximum of 17minutes to dissect. There was no donor site morbidity, the vascular fat flap was stable in all cases for up to nine years, and none of the patients complained of symptoms of Frey syndrome.

Surgical treatment of salivary malignant tumors

Salivary gland malignant tumors (SGMT) are of key interest for head and neck surgeons since surgery with adjuvant radiotherapy is considered the treatment of choice in most of the cases. Some factors, namely rarity, high histologic heterogeneity, and possible occurrence in all the head and neck subsites, contribute to make this topic very controversial; some unclear aspects pertain surgical treatment. When dealing with major salivary gland malignant tumors (MaSGMT), the most debated issues remain the extent of surgery and management of facial nerve. In minor salivary gland malignant tumors (MiSGMT), conversely, surgical planning is influenced by the specific pattern of growth of the different neoplasms as well as the site of origin of the lesion. Finally, two additional issues, the treatment of the neck (therapeutic or elective) and reconstructive strategy after ablative surgery, are of pivotal importance in management of both MaSGMT and MiSGMT. In this review, we discuss the most relevant and controversial issues concerning surgery of SGMT.

Modified superficial parotidectomy: Preserving both the great auricular nerve and the parotid gland fascia

Objective

To reduce the incidence of sensory deficits and Frey's syndrome by modifying the traditional superficial parotidectomy.

Study Design

After raising the skin flap, the parotid gland fascia (PGF) was elevated to form a posterior pedicle fascial flap and then was replaced after the gland removal. The great auricular nerve (GAN) that runs within the PGF was not separated, so both the GAN and the PGF were preserved. Before this modification, the GAN and PGF were examined anatomically. The complication rates in the modified and control groups were compared.

Results

1) The GAN, which runs within the thick and pycnotic PGF, trifurcates into postauricular, preauricular and lobule branches. The modification could be carried out practically based on the anatomy study. 2) Long-term sensory deficit was encountered in 13.3% of the control group, but 0% in the modified one. Frey's syndrome was suffered by 66.7% and 16.7% cases in the control and modified group respectively. The incidence of other complications was not significantly different.

Conclusion

Our modification is practical. It decreases the complications significantly. EBM rating: B-3b

Auriculotemporal Syndrome (Frey Syndrome)

Frey syndrome is a common sequela of parotidectomy, and although it is not frequently manifested clinically, it can cause significant morbidity for those affected. Frey syndrome results from synkinetic autonomic reinnervation by transected postganglionic parasympathetic nerve fiber within the parotid gland to the overlying sweat glands of the skin. Many surgical techniques have been proposed to prevent the development of Frey syndrome. For those who develop clinical symptoms of Frey syndrome, objective testing can be performed with a Minor starch-iodine test. Some of the current methods to prevent and treat symptomatic Frey syndrome are reviewed.

Free fat grafting in superficial parotid surgery to prevent Frey's syndrome and improve aesthetic outcome

Background:

Frey's syndrome and cosmesis are important considerations in parotid surgery. Placement of an interpositional barrier can prevent these complications; however, surgical technique and efficacy remain controversial.

Methods:

A prospective case series was collected comprising all patients undergoing primary superficial parotidectomy for benign pathology with abdominal free fat grafting between June 2007 and December 2010, performed by a single surgeon. A survey was also distributed to otorhinolaryngology consultants across Australia to assess current practice.

Results:

Twenty-eight patients were included. No patient had clinical symptoms of Frey's syndrome. Seventy-five per cent of patients were completely satisfied with their aesthetic outcome, 18 per cent scored 4/5 and the remaining 7 per cent (2 patients) scored 3/5. The survey revealed that 79 per cent of respondents did not use interpositional grafts.

Conclusion:

Abdominal free fat is ideal for grafting as it is an effective, safe, simple, accessible, fast and inexpensive method of providing an interpositional graft.

Frey's syndrome--unusually long delayed clinical onset post-parotidectomy: a case report

Frey’s syndrome is a complication of parotidectomy that is thought to occur as a result of aberrant regeneration of the postganglionic parasympathetic nerve fibres supplying the parotid gland to severed postganglionic sympathetic fibres which innervate the sweat glands of the face. Frey’s syndrome is difficult to treat but is a preventable phenomenon and surgeons must be aware of the available preventative methods during the initial surgery. An unusual case is presented involving a patient with delayed onset of Frey’s syndrome 40 years after parotidectomy in childhood. The potential for this long-delayed clinical presentation should be discussed with the patient before surgery in the parotid gland. Diagnostic methods, preventive measures and management options are briefly discussed.

Parotid carcinoma: Current diagnostic workup and treatment

In this review we present recent progress in diagnostic workup, prognostic evaluation, treatment options and resulting outcomes. Whenever possible, complete resection remains the mainstay of treatment. Sacrifice of facial nerve branches is reserved for the clinically or electromyographically dysfunctioning facial nerve. Clinical or radiological neck disease demands combined surgery and radiotherapy. Treatment of the N0 neck is indicated for advanced stage-high grade tumors but the question remains unanswered whether this should be surgical or radiotherapeutic elective treatment. Surgery alone will cure low stage, low grade tumors, that show no additional negative prognostic factors following adequate resection. In all other tumors postoperative radiotherapy will improve locoregional control. This approach results in good locoregional control, in a way that distant metastasis remains the typical presentation of treatment failure. In this setting, the results of systemic treatment today remain limited, but a huge effort in the molecular biology field has been done to introduce targeted therapy into this domain of head and neck cancer. Disease control remains variable within the patient population. This variation can increasingly be predicted by systems that incorporate the combined information of multivariately identified and quantified prognostic factors into an individualized prognosis for the parotid carcinoma patient.

[Facelift incision parotidectomy: preliminary report]

INTRODUCTION

Traditional approaches parotidectomy leaves a visible scar and a hollow on the face and neck, which might be dissappointing to some patients.

AIM OF THE STUDY

Assessment of usefulness of facelift approach to the parotid gland

PATIENT AND METHODS

A retrospective study was performed. In June 2009 eight patients with benign parotid tumour underwent superficial parotidectomy. Four of them were included in the rhytidectomy approach parotidectomies and SMAS advancement flap was carried out to reconstruct the parotid bed and prevent Frey's syndrome. The latter patients underwent the classical technique parotidectomies. After two months from the operation both groups of patients were asked to assess the cosmetic outcome of the surgery in five degree scale.

RESULTS

The duration of the operation increased by an average of 20 minutes in the rhytidectomy approach group. No major difficulties in exposing the facial nerve and its branches were observed. Patients were more satisfied when facelift approach was performed.

CONCLUSION

A rhytidectomy approach to the parotid gland seems to be safe method and aesthetic results are more satisfactory as comparing to classical approach.

A comparison between endoscope-assisted partial parotidectomy and conventional partial parotidectomy

OBJECTIVE: To report the feasibility of endoscope-assisted parotidectomy with an ultrasonic scalpel.

STUDY DESIGN: Randomized clinical trial.

SUBJECTS AND METHODS: A total of 38 patients were randomly assigned to conventional (20 patients) or endoscope-assisted (18 patients) partial parotidectomy. Via retrograde approach, endoscopic and surgical instruments were inserted through two 20- to 25-mm incisions (retromandibular and postauricular).

RESULTS: The endoscopic surgery lasted for 108.61 ± 11.86 minutes and the bleeding volume was significantly lower than in the conventional group. All 18 patients were satisfied with their cosmetic results; 14 patients (65%) were satisfied with the great auricular nerve preservation; only one patient had temporary facial paresis and salivary fistula. There was no tumor recurrence in both groups during the follow-up after 26 to 40 months) the endoscope-assisted parotidectomy group (median 30 months, range 26–40 months) and conventional group (median 32 months, range 26–40 months).

CONCLUSION: Endoscope-assisted parotidectomy is a feasible technique. This procedure may serve as an alternative approach that allows a smaller incision.

Lucja Frey--historical relevance and syndrome review

BACKGROUND

This article documents an objective review ofthe neuro-anatomical, diagnostic and clinical implications of the auriculotemporal syndrome (Frey's syndrome). The incidence of Frey's syndrome after parotidectomy as cited in the literature varies. It may also be a sequela to a variety of inflammatory, infective and traumatic aetiologies.

METHOD

An electronic search using the search engine Google, Medline and Pubmed was performed under 'Lucja Frey', 'Gustatory sweating', 'The auriculotemporal syndrome', 'Botulinum toxin'. Relevant papers were systematically reviewed from 1965 to present.

CONCLUSIONS

This disorder is important for ENT surgeons and allied specialties. We present the main surgical and cosmetic therapeutic strategies in the literature. We also discuss the fascinating life of Lucja Frey. As one of the first female academic neurologists in Europe, her career and life were tragically altered by the events of World War II.

'Minor' morbidity after parotid surgery via the modified Blair incision

OBJECTIVE

To assess the 'minor' morbidities subjectively experienced by the patient after parotid surgery; these include scar cosmesis and pain, 'contour' deformity following removal of parotid bulk, numbness of the pinna and gustatory sweating.

DESIGN

Retrospective study

SETTING

Tertiary Referral Centre.

PATIENTS

28 patients were included in the study.

RESULTS

Contour deformity, scarring and paraesthesia of the pinna secondary to great auricular nerve sacrifice are the most noticeable sequelae following parotidectomy.

DISCUSSION

Although facial nerve injury is the most serious morbidity following parotidectomy, it is relatively uncommon. Other 'minor' morbidities are more likely to cause post-operative problems. Despite there being a number of different approaches to the parotidectomy, with or without reconstruction, these have not been satisfactorily compared.

Minimal incision in parotidectomy

Conservative parotidectomy has been for years an effective and well-established technique. Recently, aesthetic considerations have been reviewed. A minimal pre- and retroauricular incision is proposed that does not extend to the hair-bearing skin. This reduces the length of the scar and the extent of the dissection improving aesthetic results. This is a retrospective study of 32 parotidectomies performed through this incision because of benign parotid diseases and diagnosed by fine needle aspiration cytology. The minimal incision is mainly indicated in small and medium-sized tumours located in the superficial lobe of the parotid gland. Neither operating time nor the morbidity associated with parotidectomy is increased with this safe and effective technique for the treatment of benign parotid masses.

Rhytidectomy and parotidectomy combined in the same patient

Until now, aesthetic goals in parotid surgery have seldom been addressed because oncologic concerns have largely overshadowed aesthetic issues for patients with parotid masses. Fortunately, the majority of parotid masses are benign pleomorphic adenomas that rarely recur, leaving a large group of patients healthy after their parotid surgery, with some desiring aesthetic improvement in their facial appearance. Traditional parotidectomy incisions leave a visible scar on the neck as well as a visible hollow in the retromandibular region, which can extend onto the cheek. A rhytidectomy approach to the parotid gland allows for a more concealed, aesthetically appealing scar while maintaining good visibility and access to the parotid gland. By performing bilateral sub-SMAS (superficial musculoaponeurotic system) rhytidectomy after a parotidectomy, facial symmetry and balance is enhanced, and these aesthetic deformities can be minimized. The SMAS flap can help to fill the hollow and form a tissue barrier over the resected gland to prevent gustatory sweating. Finally, the incision scarring is minimized with a rhytidectomy-type approach. Two cases are reported in which patients underwent both rhytidectomy and parotidectomy. In the one case, the procedures were performed in the same surgical setting. In the other case, they were performed in a delayed fashion. These cases exemplify the possibility of addressing facial aesthetic goals of rejuvenation in a patient requiring parotid resection.

Parotidectomy: Assessment of a surgical technique including facelift incision and SMAS advancement

BACKGROUND

Despite its proven safety and its relevance regarding the cosmetic outcome, the SMAS-lifting technique is not a routine procedure for many surgeons.

AIM

To compare the classical (subcutaneous flap and neck incision) with the SMAS-lifting techniques for parotidectomies from the patient's perspective.

PATIENTS AND METHODS

Both procedures are described, tricks are pointed out. In both procedures the posterior branch of the great auricular nerve was not preserved, hence the two procedures were not evaluated regarding sensitivity of the auricle and preauricular area. Forty consecutive patients were asked to classify their concerns before (1-4 months) and 1 year after surgery (10 classical technique and 30 SMAS-lifting technique).

RESULT

Before parotidectomy, patients were concerned in a decreasing order with the facial nerve function, the scar, the soft-tissue defect in the dorsal part of the cheek and Frey's syndrome. Following use of the classical technique, patients were concerned in decreasing order with the soft-tissue defect, the scar and Frey's syndrome. Following the SMAS technique, no one was concerned with the scar, Frey's syndrome, or the soft tissue defect although a slight asymmetry could still be noticed.

CONCLUSION

The SMAS-lifting technique might possibly appear to offer a new standard procedure for parotidectomy, except for malignant tumours or in obese patients.

Sternocleidomastoid Muscle Flap Reconstruction during Parotidectomy to Prevent Frey's Syndrome and Facial Contour Deformity

We studied the incidence of Frey's syndrome and facial contour deformity in two groups of patients who had undergone superficial parotidectomy. One group was made up of 12 patients who were randomized to undergo reconstruction of the surgical defect with a sternocleidomastoid muscle flap; the other 12 patients did not receive a flap. All 24 patients were evaluated via a short questionnaire, the starch-iodine test, and a visual examination. On the questionnaire, none of the 24 patients said they experienced abnormal facial sweating, flushing, or warmth while eating, although 6 of the 12 patients in the nonflap group had a mildly positive starch-iodine test. No patient in the flap group had a positive test. The difference between the two groups was statistically significant (p < 0.05). No statistically significant difference was seen between the two groups with respect to cosmetic results.