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An evidence-based approach to parotid surgery for benign and malignant tumours
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 47 (2009) 338–343
BAOMS Annual Scientific Meeting, Bournemouth, 3–5 June 2009 Masterclass abstracts
An evidence-based approach to parotid surgery for benign and malignant tumours Cyrus Kerawala Consultant Maxillofacial/Head and Neck Surgeon, The Royal Marsden Hospital, London, UK Salivary gland tumours account for fewer than 3% of head and neck neoplasms, with around 85% occurring in the parotid glands. The majority present as localised, painless and mobile swellings which are invariably benign. Within the United Kingdom surgeons vary in their approach to the management of parotid tumours, not only in terms of the surgical techniques used to remove them but also in respect of their investigation and post-operative care. Many clinicians routinely image parotid tumours with either ultrasound or cross-sectional techniques even though there is evidence that such intervention does not affect the surgical management of superficial lobe tumours.1 Pre-operative imaging is however of proven benefit in tumours which clinically appear to involve the deep lobe or parapharyngeal space as well as those suspicious of malignancy since it provides additional information that may alter the surgical approach to eradicate disease. Likewise controversy surrounds the need or otherwise of pre-operative cytology even though it is a well-established tool for investigating many head and neck conditions. Aspiration cytology has a specificity of around 95%. Its sensitivity can be increased from around 65% to 85% by combining it with ultrasound.2 In some hands the use of image-guided fine needle core biopsy further improves this sensitivity and specificity.3 Within the operating room the techniques for benign tumour surgery likewise vary. The rhytidectomy approach provides equal access to all regions of the parotid gland when compared to the more standard Blair’s incision whilst achieving superior aesthetics. Preservation of the posterior branch
0266-4356/$ – see front matter
of the great auricular nerve where possible is valuable in reducing the post-operative sensory disturbance of conventional surgery and helps to improve the quality of life of some patients.4 There is no significant difference in the incidence of post-operative complications (facial nerve palsy, Frey’s syndrome, haematoma, and wound infection) between patients undergoing conventional antegrade dissection of the facial nerve and those in whom a retrograde dissection is carried out.5 Although there are no studies that have demonstrated improved outcomes with intra-operative facial nerve monitoring it is often used as a routine particularly in units performing more than 10 parotidectomies a year and those in which training is carried out.6 Intra-operative frozen-section diagnosis is of established benefit in some institutions allowing further surgery to be performed at the initial operation in appropriate circumstances. The use of a sternocleidomastoid flap turned into the post-operative defect has not been demonstrated to be of benefit in its ability to reduce Frey’s syndrome and improve cosmesis, but the reverse has been shown for SMAS flaps.7 Perhaps the greatest controversy in the management of benign parotid tumours is the extent of surgery that is required to obtain an adequate margin. The major outcomes of surgical treatment for small pleomorphic adenomas (capsular exposure, tumour-facial nerve interface, capsular rupture, recurrence and permanent facial nerve dysfunction) are not significantly altered by the amount of parotid tissue sacrificed, be that total parotidectomy, partial superficial parotidectomy or extra-capsular dissection.8 Total parotidectomy results in higher rates of transient facial nerve dysfunction and Frey’s syndrome. Simple enucleation on the other hand provides unacceptably high recurrence rates (in excess of 10%). Focal capsular exposure occurs in virtually all cases of parotid surgery where tumours lie close to the facial nerve. Intra-operative tumour spillage raises the question of whether radiotherapy should be performed since
Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) 338–343
surgery for recurrent disease has a high incidence of permanent nerve injury. Adjuvant radiotherapy is also of benefit in the established cases of multinodular recurrent pleomorphic adenoma although its role in uninodular disease is less obvious. There is no universally agreed method for managing parotid malignancy; however, prognosis and management are related to two main variables, namely histological classification/grade of tumour and staging. The only other predictor of adverse prognosis reported in several series is advancing age. In general T1 and T2 low grade tumours are treated by parotidectomy with preservation of the facial nerve. The rate of occult metastases ranges between 15% and 40% with some retrospective evidence that elective neck dissections improves disease-free cervical. Such elected dissections should encompass levels I, II, III and Va.9 In T1 and T2 high grade tumours treatment includes parotidectomy along with first echelon node removal and post-operative radiotherapy.10 T3 tumours diagnosed with clinical or radiological evidence of cervical metastases are treated with radical parotidectomy, sacrifice of the facial nerve if it is adherent to/imbedded by tumour, comprehensive neck dissection and post-operative radiotherapy. T4 tumours and those with significant local extension may require extended radical parotidectomy with removal of skin, muscle and bone as indicated.
References 1. Cheung RL, Russell AC, Freeman J. Does routine preoperative imaging of parotid tumours affect surgical management decision-making? J Otolaryngol Head Neck Surg 2008;37:430–4. 2. Bajaj Y, Singh S, Cozens N, Sharp J. Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours. J Laryngol Otol 2005;119:289–92. 3. Breeze J, Andi A, Williams MD, Howlett DC. The use of fine needle core biopsy under ultrasound guidance in the diagnosis of a parotid mass. Br J Oral Maxillofac Surg 2009;47:78–9. 4. Yokoshima K, Nakamizo M, Ozu C, Fukumoto A, Inai S, Baba S, et al. Significance of preserving the posterior branch of the great auricular nerve in parotidectomy. J Nippon Med Sch 2004;71:323–7. 5. Anjum K, Revington PJ, Irvine GH. Superficial parotidectomy: antegrade compared with modified retrograde dissections of the facial nerve. Br J Oral Maxillofac Surg 2008;46:433–4. 6. Lowry TR, Gal TJ, Brennan JA. Patterns of use of facial nerve monitoring during parotid gland surgery. Otolaryngol Head Neck Surg 2005;133:313–8. 7. Kerawala CJ, McAloney N, Stassen LF. Prospective randomised trial of the benefits of a sternocleidomastoid flap after superficial parotidectomy. Br J Oral Maxillofac Surg 2002;40:468–72. 8. Witt RL. The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 2002;112:2141–54. 9. Teymoortash A, Werner JA. Value of neck dissection in patients with cancer of the parotid gland and a clinical NO neck. Onkologie 2002;25:122–6. 10. Bhattacharyya N, Fried MP. Determinants of survival in parotid gland carcinoma: a population-based study. Am J Otolaryngol 2005;26: 39–44.
doi:10.1016/j.bjoms.2009.04.002
339
Aesthetic blepharoplasty V. Ilankovan Consultant Oral and Maxillofacial Surgeon, Poole Hospital NHS Trust, Poole, UK Aesthetic blepharoplasty plays a vital role in periorbital rejuvenation. Mostly it is part of anti-ageing correcting measures and in some to resolve hereditary problems. It is also used as an access to other aesthetic procedures. The eyelids are divided into anterior, middle and posterior lamellae. They contain pre and retro septal fats. Orbicularis oculi, levator and Müller’s muscles are closely involved. Tarsus and septum act as curtain rail and curtain respectively with the medial and lateral canthal ligaments playing a role in the stabilisation of the lids. The lacrimal glands and nasolacrimal apparatus are closely related anatomical structures. Preoperative evaluation should include a thorough medical and ophthalmic history along with a vision examination. Baseline tear production, intrinsic lid tone, lower eyelid support using snap back test and presence of malar support are important preoperative assessments. Symptoms of preexisting dry eye should be evaluated preoperatively as they directly correlate with postoperative complication. Lateral brow ptosis, hooding of the upper eyelid, ill defined supra tarsal fold, bulky lacrimal gland and medial fat herniation are the commonest upper lid cosmetic problems. Fat herniation of a different degree with tear trough and malar palbebral groove, excess skin and loss of canthal definition are the lower eyelid problems. The shape of the eyebrow, crows feet, glabella lines, ROOF and SOOF and the quality of the overlying skin are the related problems which may need simultaneous rejuvenation. The concept of any aesthetic procedure is to achieve an outcome akin to a gourmet dish as one should not be able to identify what went in to achieve the delicious taste. This applies to blepharoplasty in total. Lateral brow correction should be used for the majority of the time with upper blepharoplasty. Other suspension sutures to provide contoured brow should be considered. Medial brow lift with a diamond scalp excision is a useful technique. Deep sutures are important to establish defined supra tarsal fold particularly in the oriental population. Fat excision is to be discouraged in lower lid blepharoplasty. Supra periosteal fat reposition like an apron flap with subcutaneous stabilisation and simultaneous lateral canthopexy are the advances. Maintaining sensation of the surgical site gain momentum, hence skin muscle flap is preferable to skin flap. SOOF plication and MAG-5 procedures should be considered to augment the outcome of blepharoplasty. Pinch excision with transconjunctival fat repositioning has produced good outcome in the literature. Transconjunctival fat repositioning with erbium laser resurfacing are preferred procedures in younger patients particularly of familial fat herniation. Chemical deinnervation using Botox fillers particularly autologous fat, to correct tear trough and augment malar mound are adjunctive procedures.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 338–343
BAOMS Annual Scientific Meeting, Bournemouth, 3–5 June 2009 Masterclass abstracts
An evidence-based approach to parotid surgery for benign and malignant tumours Cyrus Kerawala Consultant Maxillofacial/Head and Neck Surgeon, The Royal Marsden Hospital, London, UK Salivary gland tumours account for fewer than 3% of head and neck neoplasms, with around 85% occurring in the parotid glands. The majority present as localised, painless and mobile swellings which are invariably benign. Within the United Kingdom surgeons vary in their approach to the management of parotid tumours, not only in terms of the surgical techniques used to remove them but also in respect of their investigation and post-operative care. Many clinicians routinely image parotid tumours with either ultrasound or cross-sectional techniques even though there is evidence that such intervention does not affect the surgical management of superficial lobe tumours.1 Pre-operative imaging is however of proven benefit in tumours which clinically appear to involve the deep lobe or parapharyngeal space as well as those suspicious of malignancy since it provides additional information that may alter the surgical approach to eradicate disease. Likewise controversy surrounds the need or otherwise of pre-operative cytology even though it is a well-established tool for investigating many head and neck conditions. Aspiration cytology has a specificity of around 95%. Its sensitivity can be increased from around 65% to 85% by combining it with ultrasound.2 In some hands the use of image-guided fine needle core biopsy further improves this sensitivity and specificity.3 Within the operating room the techniques for benign tumour surgery likewise vary. The rhytidectomy approach provides equal access to all regions of the parotid gland when compared to the more standard Blair’s incision whilst achieving superior aesthetics. Preservation of the posterior branch
0266-4356/$ – see front matter
of the great auricular nerve where possible is valuable in reducing the post-operative sensory disturbance of conventional surgery and helps to improve the quality of life of some patients.4 There is no significant difference in the incidence of post-operative complications (facial nerve palsy, Frey’s syndrome, haematoma, and wound infection) between patients undergoing conventional antegrade dissection of the facial nerve and those in whom a retrograde dissection is carried out.5 Although there are no studies that have demonstrated improved outcomes with intra-operative facial nerve monitoring it is often used as a routine particularly in units performing more than 10 parotidectomies a year and those in which training is carried out.6 Intra-operative frozen-section diagnosis is of established benefit in some institutions allowing further surgery to be performed at the initial operation in appropriate circumstances. The use of a sternocleidomastoid flap turned into the post-operative defect has not been demonstrated to be of benefit in its ability to reduce Frey’s syndrome and improve cosmesis, but the reverse has been shown for SMAS flaps.7 Perhaps the greatest controversy in the management of benign parotid tumours is the extent of surgery that is required to obtain an adequate margin. The major outcomes of surgical treatment for small pleomorphic adenomas (capsular exposure, tumour-facial nerve interface, capsular rupture, recurrence and permanent facial nerve dysfunction) are not significantly altered by the amount of parotid tissue sacrificed, be that total parotidectomy, partial superficial parotidectomy or extra-capsular dissection.8 Total parotidectomy results in higher rates of transient facial nerve dysfunction and Frey’s syndrome. Simple enucleation on the other hand provides unacceptably high recurrence rates (in excess of 10%). Focal capsular exposure occurs in virtually all cases of parotid surgery where tumours lie close to the facial nerve. Intra-operative tumour spillage raises the question of whether radiotherapy should be performed since
Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) 338–343
surgery for recurrent disease has a high incidence of permanent nerve injury. Adjuvant radiotherapy is also of benefit in the established cases of multinodular recurrent pleomorphic adenoma although its role in uninodular disease is less obvious. There is no universally agreed method for managing parotid malignancy; however, prognosis and management are related to two main variables, namely histological classification/grade of tumour and staging. The only other predictor of adverse prognosis reported in several series is advancing age. In general T1 and T2 low grade tumours are treated by parotidectomy with preservation of the facial nerve. The rate of occult metastases ranges between 15% and 40% with some retrospective evidence that elective neck dissections improves disease-free cervical. Such elected dissections should encompass levels I, II, III and Va.9 In T1 and T2 high grade tumours treatment includes parotidectomy along with first echelon node removal and post-operative radiotherapy.10 T3 tumours diagnosed with clinical or radiological evidence of cervical metastases are treated with radical parotidectomy, sacrifice of the facial nerve if it is adherent to/imbedded by tumour, comprehensive neck dissection and post-operative radiotherapy. T4 tumours and those with significant local extension may require extended radical parotidectomy with removal of skin, muscle and bone as indicated.
References 1. Cheung RL, Russell AC, Freeman J. Does routine preoperative imaging of parotid tumours affect surgical management decision-making? J Otolaryngol Head Neck Surg 2008;37:430–4. 2. Bajaj Y, Singh S, Cozens N, Sharp J. Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours. J Laryngol Otol 2005;119:289–92. 3. Breeze J, Andi A, Williams MD, Howlett DC. The use of fine needle core biopsy under ultrasound guidance in the diagnosis of a parotid mass. Br J Oral Maxillofac Surg 2009;47:78–9. 4. Yokoshima K, Nakamizo M, Ozu C, Fukumoto A, Inai S, Baba S, et al. Significance of preserving the posterior branch of the great auricular nerve in parotidectomy. J Nippon Med Sch 2004;71:323–7. 5. Anjum K, Revington PJ, Irvine GH. Superficial parotidectomy: antegrade compared with modified retrograde dissections of the facial nerve. Br J Oral Maxillofac Surg 2008;46:433–4. 6. Lowry TR, Gal TJ, Brennan JA. Patterns of use of facial nerve monitoring during parotid gland surgery. Otolaryngol Head Neck Surg 2005;133:313–8. 7. Kerawala CJ, McAloney N, Stassen LF. Prospective randomised trial of the benefits of a sternocleidomastoid flap after superficial parotidectomy. Br J Oral Maxillofac Surg 2002;40:468–72. 8. Witt RL. The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 2002;112:2141–54. 9. Teymoortash A, Werner JA. Value of neck dissection in patients with cancer of the parotid gland and a clinical NO neck. Onkologie 2002;25:122–6. 10. Bhattacharyya N, Fried MP. Determinants of survival in parotid gland carcinoma: a population-based study. Am J Otolaryngol 2005;26: 39–44.
doi:10.1016/j.bjoms.2009.04.002
339
Aesthetic blepharoplasty V. Ilankovan Consultant Oral and Maxillofacial Surgeon, Poole Hospital NHS Trust, Poole, UK Aesthetic blepharoplasty plays a vital role in periorbital rejuvenation. Mostly it is part of anti-ageing correcting measures and in some to resolve hereditary problems. It is also used as an access to other aesthetic procedures. The eyelids are divided into anterior, middle and posterior lamellae. They contain pre and retro septal fats. Orbicularis oculi, levator and Müller’s muscles are closely involved. Tarsus and septum act as curtain rail and curtain respectively with the medial and lateral canthal ligaments playing a role in the stabilisation of the lids. The lacrimal glands and nasolacrimal apparatus are closely related anatomical structures. Preoperative evaluation should include a thorough medical and ophthalmic history along with a vision examination. Baseline tear production, intrinsic lid tone, lower eyelid support using snap back test and presence of malar support are important preoperative assessments. Symptoms of preexisting dry eye should be evaluated preoperatively as they directly correlate with postoperative complication. Lateral brow ptosis, hooding of the upper eyelid, ill defined supra tarsal fold, bulky lacrimal gland and medial fat herniation are the commonest upper lid cosmetic problems. Fat herniation of a different degree with tear trough and malar palbebral groove, excess skin and loss of canthal definition are the lower eyelid problems. The shape of the eyebrow, crows feet, glabella lines, ROOF and SOOF and the quality of the overlying skin are the related problems which may need simultaneous rejuvenation. The concept of any aesthetic procedure is to achieve an outcome akin to a gourmet dish as one should not be able to identify what went in to achieve the delicious taste. This applies to blepharoplasty in total. Lateral brow correction should be used for the majority of the time with upper blepharoplasty. Other suspension sutures to provide contoured brow should be considered. Medial brow lift with a diamond scalp excision is a useful technique. Deep sutures are important to establish defined supra tarsal fold particularly in the oriental population. Fat excision is to be discouraged in lower lid blepharoplasty. Supra periosteal fat reposition like an apron flap with subcutaneous stabilisation and simultaneous lateral canthopexy are the advances. Maintaining sensation of the surgical site gain momentum, hence skin muscle flap is preferable to skin flap. SOOF plication and MAG-5 procedures should be considered to augment the outcome of blepharoplasty. Pinch excision with transconjunctival fat repositioning has produced good outcome in the literature. Transconjunctival fat repositioning with erbium laser resurfacing are preferred procedures in younger patients particularly of familial fat herniation. Chemical deinnervation using Botox fillers particularly autologous fat, to correct tear trough and augment malar mound are adjunctive procedures.