Reconstructive trends and complications following parotidectomy: incidence and predictors in 11,057 cases

Risk factors and outcomes after surgery for malignant neoplasm of the parotid gland: An ACS-NSQIP study

BACKGROUND

Malignant neoplasms of the parotid gland (MPG) are clinically challenging due to aggressive growth and metastasis. Despite tumor resection being the primary treatment, there is a paucity of studies on postsurgical outcomes and preoperative risk factors for MPG.

MATERIALS AND METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent MPG surgery between 2008 and 2021. 30-day postoperative outcomes and risk factors predisposing to the occurrence of complications were assessed.

RESULTS

The study population included 3052 patients, the majority of whom were males (n = 1842; 60%) and White (n = 2017; 66%). The average age was 63 ± 16 years. The most common comorbidities were obesity (n = 1182; 39%) and hypertension (n = 1533; 50%). Surgical procedures were performed predominantly in the inpatient setting (n = 1773; 58%) by ENT surgeons (n = 2767; 91%). Overall, complications were reported in 6.8% (n = 209) of patients. Inpatient setting (p < 0.001), renal failure (p < 0.001), smoking (p = 0.012), as well as increased creatinine (p < 0.001) and blood urea nitrogen (BUN) levels (p = 0.001) were identified as risk factors for complications. In addition, concurrent microsurgical procedures such as flap surgery and/or nerve grafting significantly increased the risk of postoperative adverse events (p < 0.001).

CONCLUSIONS

Our analysis revealed that complication rates were associated with high creatinine and BUN levels, inpatient surgery, renal failure, higher American Society of Anesthesiology classes, and smoking. We also found that concurrent microsurgical procedures were predictive factors for complications. These findings can inform patient counseling, preoperative planning, and risk stratification.

Nerve-Sparing Parotidectomy Guided by Nerve Auto-Fluorescence Technology

Parotidectomy is a commonly performed surgery for various indications, including inflammatory conditions, infection, congenital symptomatic malformations, and neoplasm resection. Irrespective of its indication, the performance requires meticulous surgical navigation by highly experienced surgeons because of its proximity to the facial nerve. While the surgical technique continues to evolve, nerve paralysis and nerve-related complications remain a significant concern following an intervention. Due to the high learning curve required to reduce the incidence of surgical iatrogenic events, a novel device has been developed to emit real-time nerve auto-fluorescence in parallel to artificial intelligence (AI) surgical navigation software (SNS) feedback to isolate and accurately identify nerve structures during surgery. The authors herein present one of the first cases of a benign parotid tumor excision implementing dual AI and nerve auto-fluorescence technology for a minimally invasive, nerve-sparing parotidectomy. This report underscores the potential of nerve auto-fluorescence-guided surgery to improve surgical precision and patient outcomes.

Management of Indeterminate Thyroid Nodules: A Model Comparing Surgery, Molecular Testing, and Observation

OBJECTIVE

Optimal management of indeterminate nodules remains a controversial area of endocrine surgery. The purpose of this study is to compare observation, molecular testing, and immediate thyroid surgery for the management of Bethesda Classes III and IV nodules in patients age 50 to 90 years.

STUDY DESIGN

A decision analysis was performed from April 22, 2021, to September 29, 2023, using a Markov model constructed with TreeAgePro 2023. Model variables and ranges were selected based on literature review data.

SETTING

TreeAgePro.

METHODS

A 1-way sensitivity analysis was performed to evaluate the age threshold at which each management pathway, immediate thyroid surgery, additional molecular testing, or observation, would be favored. A Monte Carlo probabilistic sensitivity analysis was performed 5 times with model patients assigned starting ages of 50, 60, 70, 80, and 90 years to assess how age at diagnosis would impact model results. Outcomes were measured with quality-adjusted life-years and accounted for perioperative complications including permanent recurrent laryngeal nerve injury, permanent hypoparathyroidism, and medical complications.

RESULTS

In the study models, molecular testing was more beneficial than surgery and observation across all ages. The age threshold at which observation became more beneficial than surgery as the next best option was 83.1 years. However, the clinical difference between all 3 treatment algorithms was relatively minimal.

CONCLUSIONS

Decision-making regarding indeterminate thyroid nodules is complex. Given the clinically similar results across all 3 treatment algorithm, this study reinforces that treatment modalities should be individually tailored and based on shared physician-patient decision making.

An analysis of health-related quality of life in children and adolescents after parotidectomy based on patient-reported outcomes

PURPOSE

To assess health-related quality of life (HRQoL) and its influencing factors in these pediatric patients undergoing parotidectomy.

METHODS

This was a cross-sectional study that included 37 children and adolescents (≤ 19 years) with parotid gland tumors who were treated in Sichuan Cancer Hospital between January 2006 and November 2021. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30). The Wilcoxon rank sum test was used to analyze the factors influencing patients' HRQoL.

RESULTS

37 children and adolescents were included in the study, including 22 cases of benign tumors and 15 cases of malignant tumors. All patients underwent surgery, and some patients with malignant tumors received radiotherapy or chemotherapy. Malignancy, permanent facial palsy, and Frey syndrome were associated with worse HRQoL in children and adolescents with parotid gland tumors. Radiotherapy and no cervical lymph node dissection were associated with worse HRQoL in pediatric patients with malignancy. The surgical approach of parotid is not a factor influencing HRQoL.

CONCLUSION

Factors associated with HRQoL in children and adolescents with parotid gland tumors include pathological types, permanent facial palsy, and Frey syndrome. In addition, factors affecting patients with malignancy include lateral lymph node dissection and radiotherapy.

Adverse events associated with anastomotic coupling devices in microvascular reconstruction

OBJECTIVE

In light of the recent US Food and Drug Administration (FDA) Class 2 safety recall notice for anastomotic coupling devices, it is important to understand related adverse events. The aim of this study was to characterize adverse events in anastomotic coupling devices for microvascular reconstruction.

METHODS

A retrospective cross-sectional analysis using the 2011 to 2021 US FDA Manufacturer and User Facility Device Experience (MAUDE) database. All reports of adverse events involving anastomotic coupling devices were retrieved from the MAUDE database. Descriptive statistics were used to analyze categorized events.

RESULTS

There were a total of 293 documented adverse events related to anastomotic coupling devices. These adverse events resulted in 91 (31.1 %) patient injuries and 239 (81.6 %) device malfunctions. The most frequent patient problems were thrombosis/hematoma (n = 38; 41.8 %), unspecified injury (n = 31; 34.1 %), and failure to anastomose (n = 13; 14.3 %). Free flap necrosis was reported in 42 % of thrombosis/hematoma cases (n = 16). The most common malfunctions were devices operating differently than expected (n = 74; 31.0 %), connection problems (n = 41; 17.2 %), and twisted/bent material (n = 19; 7.9 %). There was no significant trend in the number of adverse events over the study period (p > 0.05).

CONCLUSIONS

Adverse events from anastomotic coupling devices represent an important and modifiable factor in free tissue failure. Adverse events are predominately related to devices operating differently than expected and may result in vascular compromise of the free flap. Reconstructive surgeons should be cognizant of defective anastomotic coupling devices and be prepared to utilize traditional hand-sewn anastomosis.

A Novel Approach to Facial Reanimation and Restoration Following Radical Parotidectomies

Background: Parotidectomies are indicated for a variety of reasons. Regardless of the indication for surgery, facial reanimation may be required because of facial nerve sacrifice or iatrogenic damage. In these cases, facial restoration performed concurrently with ablative surgery is considered the gold standard, and delayed reanimation is usually not attempted. Methods: A retrospective review of all patients who underwent parotidectomies from 2009 to 2022 in a single institution was performed. Indications, surgical techniques, and outcomes of an algorithmic template were applied to these cases using the Sunnybrook, Terzis scores, and Smile Index. A comparison was made between immediate vs. late repairs. Results: Of a total of 90 patients who underwent parotidectomy, 17 (15.3%) had a radical parotidectomy, and 73 (84.7%) had a total or superficial parotidectomy. Among those who underwent complete removal of the gland and nerve sacrifice, eight patients (47.1%) had facial restoration. There were four patients each in the immediate (n = 4) and late repair (n = 4) groups. Surgical techniques ranged from cable grafts to vascularized cross facial nerve grafts (sural communicating nerve flap as per the Koshima procedure) and vascularized nerve flaps (chimeric vastus lateralis and anterolateral thigh flaps, and superficial circumflex perforator flap with lateral femoral cutaneous nerve). Conclusions: The algorithm between one technique and another should take into consideration age, comorbidities, soft tissue defects, presence of facial nerve branches for reinnervation, and donor site morbidity. While immediate facial nerve repair is ideal, there is still benefit in performing a delayed repair in this algorithm.

Masseteric Nerve Transfer for Facial Paralysis Secondary to Parotid Malignancy: A Retrospective Case Series

Background: The objective outcomes of masseteric nerve transfer in the setting of parotid malignancy are unclear. Objective: To measure objective facial reanimation outcomes of masseteric nerve transfer in patients with parotid malignancy who underwent parotidectomy with facial nerve resection. Materials and Methods: Retrospective review of patients who underwent masseteric nerve transfer for facial paralysis secondary to parotid malignancy was carried out at a tertiary referral hospital from August 2017 to November 2021. Objective facial reanimation outcomes were analyzed using Emotrics. Minimal follow-up of 6 months was required for inclusion. Results: Eight patients (five males) with a median age of 75.5 years (range 53-91) met inclusion criteria. Fifty percent had metastatic squamous cell carcinoma, and 50% had primary parotid malignancy. Five patients underwent concomitant cancer resection with facial nerve reconstruction. Seven patients received postoperative adjuvant radiotherapy. After reinnervation, patients had improved oral commissure excursion (from 1.51 mm ±1.27 to 3.77 mm ±1.81; p < 0.01) and facial symmetry during smile. Conclusion: In this study, masseteric nerve transfer enhanced oral commissure excursion and facial symmetry during smile in patients with parotid malignancy and facial nerve resection.

Porous Organic Materials in Tissue Engineering: Recent Advances and Applications for Severed Facial Nerve Injury Repair

The prevalence of facial nerve injury is substantial, and the restoration of its structure and function remains a significant challenge. Autologous nerve transplantation is a common treatment for severed facial nerve injury; however, it has great limitations. Therefore, there is an urgent need for clinical repair methods that can rival it. Tissue engineering nerve conduits are usually composed of scaffolds, cells and neurofactors. Tissue engineering is regarded as a promising method for facial nerve regeneration. Among different factors, the porous nerve conduit made of organic materials, which has high porosity and biocompatibility, plays an indispensable role. This review introduces facial nerve injury and the existing treatment methods and discusses the necessity of the application of porous nerve conduit. We focus on the application of porous organic polymer materials from production technology and material classification and summarize the necessity and research progress of these in repairing severed facial nerve injury, which is relatively rare in the existing articles. This review provides a theoretical basis for further research into and clinical interventions on facial nerve injury and has certain guiding significance for the development of new materials.

Research trends and perspectives on immediate facial reanimation in radical parotidectomy (Review)

For patients diagnosed with advanced malignant parotid tumour, radical parotidectomy with facial nerve sacrifice is part of the treatment. Multiple surgical techniques have been developed to cure facial paralysis in order to restore the function and aesthetics of the face. Despite the large number of publications over time on facial nerve reanimation, a consensus on the timing of the procedure or the donor graft selection has remained to be established. Therefore, the aim of the present study was to conduct a bibliometric analysis to identify and analyse scientific publications on the reconstruction of the facial nerve of patients who underwent radical parotidectomy with facial nerve sacrifice. The analysis on the topic was conducted using the built-in tool of the Scopus database and VOSviewer software. The first 100 most cited articles were separately reviewed to address the aim of the study. No consensus was found regarding the recommended surgical techniques for facial nerve reanimation. The most used donor cranial nerves for transfer included the following: Masseteric branch of the V nerve, contralateral VII nerve with cross-face graft, the XI nerve and the XII nerve. The best timing of surgery is also controversial depending on pre-exiting pathology and degree of nerve degeneration. However, most of the clinical experience suggests facial nerve restoration immediately after the ablative procedure to reduce complications and improve patients' quality of life.

Artificial neural network prediction of post-thyroidectomy outcome

OBJECTIVES

The goal of this study was to develop a deep neural network (DNN) for predicting surgical/medical complications and unplanned reoperations following thyroidectomy.

DESIGN, SETTING, AND PARTICIPANTS

The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to extract patients who underwent thyroidectomy. A DNN consisting of 10 layers was developed with an 80:20 breakdown for training and testing.

MAIN OUTCOME MEASURES

Three primary outcomes of interest, including occurrence of surgical complications, medical complications, and unplanned reoperation were predicted.

RESULTS

Of the 21 550 patients who underwent thyroidectomy, medical complications, surgical complications and reoperation occurred in 1723 (8.0%), 943 (4.38%) and 2448 (11.36%) patients, respectively. The DNN performed with an area under the curve of receiver operating characteristics of .783 (medical complications), .709 (surgical complications) and .703 (reoperations). Accuracy, specificity and negative predictive values of the model for all outcome variables ranged 78.2%-97.2%, while sensitivity and positive predictive values ranged 11.6%-62.5%. Variables with high permutation importance included sex, inpatient versus outpatient and American Society of Anesthesiologists class.

CONCLUSIONS

We predicted surgical/medical complications and unplanned reoperation following thyroidectomy via development of a well-performing ML algorithm. We have also developed a web-based application available on mobile devices to demonstrate the predictive capacity of our models in real time.

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.

Tratamiento quirúrgico de la patología tumoral de la glándula parótida. Estudio descriptivo de 263 parotidectomías

Introducción y objetivo: Los tumores salivales representan el 3-10% de los tumores de cabeza y cuello, siendo el 75-80% de origen parotídeo y en su mayoría benignos. La parotidectomía es una técnica quirúrgica que consiste en la exéresis de la glándula parótida. Existen diversos tipos; parotidectomía superficial (PS), parotidectomía superficial parcial (PSP) y parotidectomía total (PT). En esta última, al no respetarse el nervio facial (NF), las complicaciones son más frecuentes. Nuestro objetivo es analizar el resultado (tasa de recidiva y complicaciones) de la parotidectomía como técnica quirúrgica empleada en el manejo de la patología parotídea, así como evaluar qué prueba complementaria es la más eficaz en el diagnostico prequirúrgico de la patología parotídea tumoral. Material y método: Se realiza un estudio retrospectivo incluyendo 263 pacientes tratados mediante PS o PT entre enero de 2004 y diciembre de 2020 en el Hospital Universitario de Fuenlabrada. Se registraron datos demográficos, tiempo de evolución de la lesión, pruebas complementarias, protocolo quirúrgico y complicaciones postoperatorias. Se analiza principalmente la correlación positiva entre las pruebas realizadas prequirúrgicas (PAAF, ecografía, TC y RMN), con el diagnóstico definitivo anatomopatológico obtenido tras examinar la pieza quirúrgica. También se describe la tasa de paresia y parálisis facial y otras complicaciones habidas. Resultados: Se incluyeron 263 pacientes tratados mediante parotidectomía. El tiempo de evolución medio de las lesiones parotídeas fue de 15 meses (DE 19.88). La sensibilidad de la PAAF en nuestro estudio fue de 68.7%. Se realizó ecografía en un 44.10% de los pacientes, TC en un 77.94% y RMN en un 15.20%, mostrando una sensibilidad de 18.05%, 31.21% y 45%, respectivamente. La cirugía más frecuente fue la PS (43.3%, 114/263), seguida por la PSP (41.1%, 108/263) y, por último, la menos habitual fue la PT (15.58%, 41/263). Los tumores benignos fueron más frecuentes (84.79%, 223/263), siendo el adenoma pleomorfo el más frecuente, 45.73% (102/223). Dentro del grupo de tumores malignos (15.20%, 40/263), el más habitual fue el carcinoma mucoepidermoide (17.5%, 7/40) y las metástasis (17.5%, 7/40). La paresia facial, según la escala de House-Brackmann, fue leve (grado I y II) y transitoria en la mayoría de los casos, apareciendo en un 31.55%. Tras un periodo medio de seguimiento de 6 años no se han encontrado recidivas post parotidectomía por ningún tipo tumoral en nuestro estudio. Conclusión: En nuestra muestra, los tumores benignos representaron la gran mayoría de la patología parotídea. Dentro de este grupo, el adenoma pleomorfo fue el más frecuente. La PAAF fue la prueba complementaria con mejor correlación con el diagnostico anatomopatológico definitivo, seguida por la RMN. La paresia facial leve (grados I y II) y transitoria fue la complicación postquirúrgica mas habitual.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study

OBJECTIVES

To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses.

RESULTS

A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545).

CONCLUSION

Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

Is This Novel Incision for Benign Parotid Tumors the Answer for Improved Esthetics and Access?

Background

Incision scars and postoperative cosmesis are critical in the management of benign parotid tumors. Traditional incisions have a typical visible scar in the retromandibular area or require wide skin flaps.

Purpose

In this study, we introduced a new surgical approach called the tri-split flap approach and evaluated its technical feasibility and surgical outcomes.

Materials and Methods

Eleven patients with clinically benign parotid gland tumors underwent the tri-split flap approach and were followed for six to ten months postoperatively. Facial weakness, salivary fistula formation, first bite syndrome, earlobe numbness, and the subjective cosmetic results were evaluated.

Results

All tumors were completely excised, and the patients were highly satisfied with the esthetic outcome of the surgery. No patients developed wound dehiscence, facial nerve injury, or first bite syndrome during the follow-up period. One patient developed a minor salivary fistula that resolved after three weeks.

Conclusion

The tri-split flap approach not only provides adequate exposure of the surgical site to achieve complete resection of benign parotid gland neoplasms but also results in a very short and highly concealed post-operative scar. This technique is a potential surgical approach in parotidectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-021-01605-1.

Comparing postoperative outcomes using electrocautery versus cold-knife de-epithelialization of dermal fat graft in parotidectomy reconstruction

PURPOSE

The present study was developed to evaluate the effectiveness of a simple rapid technique for de-epithelializing cutaneous flaps and grafts in parotidectomy reconstruction.

MATERIALS AND METHODS

109 patients who underwent a parotidectomy with abdominal free dermal fat graft (FDFG) reconstruction between 2018 and 2021 were evaluated based on demographic factors, past medical/surgical history, type of parotidectomy performed, operative factors, and post-operative complications. These data were then stratified based on de-epithelialization technique as well as tumor malignancy status to determine any differences in complication rates or perioperative factors between electrocautery (EC) and cold knife (CK) techniques within both benign and malignant subgroups.

RESULTS

77 of the 109 participants underwent FDFG de-epithelialization using monopolar electrocautery (EC) and the remaining 32 participants underwent de-epithelialization using traditional cold knife (CK) technique. There was no statistical difference among the two groups in overall complication rate. The EC group had a significantly shorter operation time ("EC vs. CK": 144.2 min vs. 174.7 min; p = 0.031). Additionally, histopathologic samples showed that both techniques left the underlying dermis intact and without damage.

CONCLUSIONS

This study demonstrated that there is no difference in complication rate or histology of FDFGs de-epithelialized using EC compared to CK. It was also shown that when controlling for confounders by looking solely at the benign subgroup of patients, EC de-epithelialization was a faster technique than CK. These findings suggest that EC is just as effective as CK, and may actually be a more efficient surgical technique to accomplish de-epithelialization of FDFG.

Treatment of Benign Lesion of Levels I or II of the Parotid Gland: Long Term Results of Partial Superficial Parotidectomy

ABSTRACT

The correct surgical approach to benign parotid gland tumors is still matter of debate, it should be chosen considering the possibility of local recurrence or facial nerve complications in case of "not necessary" facial nerve dissection. In the era of minimally invasive surgery, more sparing approaches such as extracapsular dissection or partial superficial parotidectomy (PSP) are gaining popularity. The aim of the study is to present surgical results and long-term outcomes of PSP (level I or II) in a large group of patients. Six hundred fifty-one patients who underwent parotid surgery between 2004 and 2020 were initially considered. Five hundred forty patients with benign lesions treated with PSP, enucleation, ECD were enrolled. Clinical features, surgical data, postoperative scarring, seroma, dehiscence, neuroma, outcomes as Frey syndrome, and delayed facial nerve dysfunction have been evaluated. 65.5% PSP, 25.2% enucleation, and 9.2% extracapsular dissection. No statistical difference in surgical time has been found (P 0.16). P > 0.05 for seroma, neuroma, Frey syndrome, and facial palsy between different type of surgery. Frey syndrome in PSP: 6/135 (4.4%) in 2004 to 2012 and 2/219 (0.9%) in 2013 to 2020. The reduction between periods is significant (P < 0.04). Recurrence: 0.8% (3/354) for PSP patients, 3.4% (5/136) in enucleation and 10% (5/50) in ECD (P = 0.02). Partial superficial parotidectomy can be considered a minimally invasive and quick procedure with low complication rate. Our data seem to support this statement (large case series and long-term follow-up).

Facial Reanimation and Reconstruction of the Radical Parotidectomy

Radical parotidectomy may result from treating advanced parotid malignancies invading the facial nerve. Survival is often enhanced with multimodality treatment protocols, including postoperative radiation therapy. In addition to the reconstructive challenge of restoring facial nerve function, patients may be left with a significant cervicofacial concavity and inadequate skin coverage. This should be addressed with stable vascularized tissue that is resistant to radiation-induced atrophy. This article describes a comprehensive strategy, includes the use of the anterolateral thigh free flap, the temporalis regional muscle transfer, motor nerve to vastus lateralis grafts, nerve to masseter transfer, and fascia lata grafts for static suspension.

Comparison of Parotidectomy With Observation for Treatment of Pleomorphic Adenoma in Adults

Importance

There is no consensus regarding optimal management of pleomorphic adenoma in adults.

Objectives

To compare parotidectomy with observation for the management of pleomorphic adenoma in patients 50 years or older by age.

Design and Setting

This decision analytical model was performed from November 21, 2019, to June 15, 2020, using a Markov model. Model variables and ranges were selected based on a literature review. A 1-way sensitivity analysis was performed to evaluate the age threshold at which each algorithm, either upfront elective parotidectomy or observation, would be favored. A Monte Carlo probabilistic sensitivity analysis using variable ranges was then performed 5 times with patients in the model assigned a starting age of 50, 60, 70, 80, and 90 years to assess how age at diagnosis would be associated with the model results.

Main Outcomes and Measures

Model outcomes were measured with quality-adjusted life-years (QALYs).

Results

In the study models, the age thresholds at which observation became more beneficial than parotidectomy were 88.5 years for patients with superficial lobe tumors (5.37 QALYs in favor of parotidectomy below this age, and 5.37 QALYs in favor of observation above this age) and 83.4 years for patients with deep lobe tumors (7.51 QALYs in favor of surgery below this age, and 7.51 QALYs in favor of observation above this age). There was no significant difference in outcomes between parotidectomy and observation among patients aged 70 to 80 years.

Conclusions and Relevance

This study suggests that the outcomes associated with parotidectomy and observation are similar at 70 years or older among patients with pleomorphic adenoma and that observation may be the favorable treatment in that age group.

Perioperative Complications after Parotidectomy Using a Standardized Grading Scale Classification System

Perioperative complications after parotidectomy are poorly studied and have a potential impact on hospitalization stay. The Clavien–Dindo classification of postoperative complications used in visceral surgery allows a recording of all complications, including a grading scale related to the severity of complication. The cohort analyzed for perioperative complications is composed of 436 parotidectomies classified into three types, four groups, and three classes, depending on extent of parotid resection, inclusion of additional procedures, and pathology, respectively. Using the Clavien–Dindo classification, complications were reported in 77% of the interventions. In 438 complications, 430 (98.2%) were classified as minor (332 grade I and 98 grade II), and 8 (1.8%) were classified as major (grade III). Independent variables affecting the risk of perioperative complications were duration of surgery (odds ratio = 1.007, p-value = 0.029) and extent of parotidectomy (odds ratio = 4.043, p-value = 0.007). Total/subtotal parotidectomy was associated with an increased risk of grade II-III complications (odds ratio = 2.866 (95% CI: 1.307–6.283), p-value = 0.009). Median hospital stay increased moderately in patients with complications. Use of Clavien–Dindo classification shows that parotidectomy is followed by a higher rate of perioperative complications than usually reported. Almost all complications are minor and have limited consequence on hospital stay.

Does neck dissection affect post-operative outcomes in parotidectomy? A national study

OBJECTIVE

To characterize post-operative complications in parotidectomy with neck dissection.

METHODS

Patients age ≥ 18 receiving a parotidectomy or parotidectomy with neck dissection between 2005 and 2017 were eligible for inclusion. Patients with unknown demographic variables were excluded. Univariate and multivariable logistic regression analyses were performed.

RESULTS

A total of 13,609 parotidectomy patients were analyzed, 11,243 (82.6%) without neck dissection and 2366 (17.4%) with neck dissection. Both length of surgery (mean minutes ± standard deviation [SD] = 335.9 ± 189.2 vs. 152.9 ± 99.0, p < 0.001) and length of hospital stay (mean days ± SD = 3.90 ± 4.76 vs. 1.04 ± 2.14, p < 0.001) were greater with dissection. 13.9% of parotidectomies with neck dissection and 3.5% without dissection (p < 0.001) had at least one complication, which remained significant after multivariable adjustment (Odds Ratio[OR] = 1.565 (95%CI = 1.279-1.914), p < 0.001). The increase in post-operative complications was predominately driven by an increased transfusion rate (7.4% vs. 0.5%, p < 0.001). Multivariable analysis also demonstrated no significant difference in rates of returning to the operating room (OR = 1.122 (95%CI 0.843-1.493), p > 0.05) or rates of readmission (OR = 1.007 (95%CI 0.740-1.369), p > 0.05). Parotidectomy with neck dissection was more likely to be inpatient (OR = 4.411 (95%CI 3.887-5.004), p < 0.001) and to be ASA class 3 (OR = 1.367 (95%CI 1.194-1.564), p < 0.001).

CONCLUSIONS

Nationwide data demonstrates that parotidectomy with neck dissection is associated with increased rates of post-operative complications; however, neck dissection did not significantly impact readmission or reoperation rates. These findings indicate that neck dissection is a relatively safe addition to parotidectomy and provide novel evidence in the management of parotid malignancies.

Advances in facial nerve management in the head and neck cancer patient

PURPOSE OF REVIEW

The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery.

RECENT FINDINGS

Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes.

SUMMARY

Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.