- Email: [email protected]
Selective deep lobe parotidectomy for pleomorphic adenomas
Int. J. Oral Maxillofac. Surg. 2013; 42: 1129–1133 http://dx.doi.org/10.1016/j.ijom.2013.04.007, available online at http://www.sciencedirect.com
Clinical Paper Clinical Pathology
Selective deep lobe parotidectomy for pleomorphic adenomas
E. Sesenna1, B. Bianchi1, S. Ferrari1, C. Copelli1, T. Ferri2, A. Ferri1 1 Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy; 2Otolaryngology Head Neck Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
E. Sesenna, B. Bianchi, S. Ferrari, C. Copelli, T. Ferri, A. Ferri: Selective deep lobe parotidectomy for pleomorphic adenomas. Int. J. Oral Maxillofac. Surg. 2013; 42: 1129–1133. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The authors’ experience of the selective deep lobe parotidectomy for the treatment of pleomorphic adenomas of the deep parotid lobe is presented. A retrospective analysis of 11 patients treated between 1997 and 2010 was performed; seven were males and four were females, ranging in age from 35 to 51 years. Parameters evaluated included facial nerve weakness, the occurrence of Frey’s syndrome, cosmetic outcome, and recurrence. Follow-up ranged from 18 months to 11 years. No major complications, permanent facial nerve weakness, or Frey’s syndrome occurred. Four patients developed temporary facial nerve impairments that lasted between 2 and 6 weeks, and two developed a sialocele that healed in 9 days in one case and 12 days in the other. The overall cosmetic assessment was excellent in eight patients, good in two, and satisfactory in the remaining one. No recurrences occurred. The selective deep lobe parotidectomy can be considered an effective technique for the management of deep parotid lobe pleomorphic adenomas. The major advantages of this procedure include a reduction in complications such as facial nerve impairments and Frey’s syndrome, and an improved cosmetic outcome.
Over the past three decades, the approach to parotid gland benign tumors has changed from superficial or total parotidectomies to partial/selective parotidectomies or extracapsular dissection.1 Despite the controversies in the international literature, a general agreement on the effectiveness of the partial parotidectomy approach is presently well established.2,3 Partial/selective parotidectomies allow complete and safe tumor removal, better functional outcomes, and a reduction in complications such as facial 0901-5027/0901129 + 05 $36.00/0
nerve impairment and Frey’s syndrome.4 Furthermore, the preservation of healthy parotid tissue allows reconstruction of the parotid bed and a reduction in facial contour deficiency, thus improving the cosmetic outcome.5 The principles of partial/selective parotidectomies have recently been extended by some authors to the management of deep parotid lobe benign tumors, shifting surgical treatment of these neoplasms from total or near total parotidectomies
Key words: parotid surgery; parotidectomy; deep lobe tumors; selective deep lobe parotidectomy. Accepted for publication 16 April 2013 Available online 20 May 2013
to selective deep lobe resections.6 This procedure preserves the superficial parotid lobe, ensuring better function and cosmesis, and reduces the complications associated with more extensive procedures.7 Despite the effectiveness of this technique, a complete literature review revealed only four papers on this topic.6–9 Authors present herein the authors’ experience of the selective deep lobe parotidectomy, discussing the surgical technique, indications, and results of this approach.
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1130
Sesenna et al. Table 1. Patients with deep parotid lobe pleomorphic adenomas treated with selective deep lobe parotidectomy.
Methods Surgical technique
Usually a standard face-lift incision is performed and a comprehensive flap of skin, subcutaneous tissue, and superficial musculo-aponeurotic system (SMAS) tissue is elevated. The flap is dissected less far forward than a standard superficial parotidectomy to preserve some vascularization to the superficial parotid lobe that will later be dissected. The great auricular nerve and its posterior branch are identified on the surface of the sternocleidomastoid muscle, dissected and preserved. The main trunk of the facial nerve is identified using classical landmarks and by electrostimulation, if needed, and is carefully dissected. The facial nerve division is identified and the superficial lobe of the parotid is elevated from behind, with dissection of the facial nerve branches. In seven cases, the superficial lobe was also split into two halves (superior and inferior) to achieve an easier and quicker approach to the deep lobe. The superficial lobe (in one or two pieces) is left pedicled anteriorly. Once the tumor is identified it is preferable to free completely (also in the deep surface) only those nerve branches that it is essential to dissect in order to achieve a complete and safe dissection of the tumor. In this way the tumor is dissected below the plane of the facial nerve and removed, if possible, with a cuff of healthy deep lobe glandular tissue. Then the superficial parotid lobe is repositioned and sutured to the pre-tragal tissues and to the sternocleidomastoid muscle with resorbable sutures, achieving a complete reconstruction of the parotid fascia. A suction drain is placed and the skin flap is repositioned and sutured by planes.
Patient, sex and age
Side
FNAB result
Imaging
Male, 49 years Female, 39 years Female, 48 years Male, 42 years Female, 41 years Female, 51 years Female, 40 years Male, 45 years Female, 44 years Male, 37 years Female, 35 years
Right Left Right Left Right Right Right Left Right Right Right
Pleomorphic adenoma Pleomorphic adenoma Non-diagnostic Pleomorphic adenoma Pleomorphic adenoma Pleomorphic adenoma Pleomorphic adenoma Non-diagnostic Pleomorphic adenoma Pleomorphic adenoma Pleomorphic adenoma
CT MRI MRI CT MRI MRI MRI MRI CT MRI MRI
FNAB, fine-needle aspiration biopsy; CT, computed tomography; MRI, magnetic resonance imaging.
Patients
From 1 January 1997 to 31 December 2010, 368 patients were treated for benign tumors affecting the parotid gland. A retrospective evaluation of the clinical data revealed 11 cases of deep parotid lobe pleomorphic adenoma treated with a selective deep lobe parotidectomy; these cases were included in the study. Patient data are summarized in Table 1. The study was granted exemption from institutional review board approval due its retrospective nature and was performed in compliance with the World Medical Association Declaration of Helsinki on medical research protocols and ethics. Seven patients were female and four male, ranging in age from 35 to 51 years (mean 42.8 years). The right parotid was involved in eight cases and the left in the remaining three. Preoperative assessment included ultrasound (US) and fine-needle aspiration biopsy (FNAB), followed by magnetic resonance imaging (MRI) or contrast enhanced computed tomography (CT) in
all cases (eight MRI and three CT). FNAB was diagnostic for pleomorphic adenoma in nine patients, but was non-diagnostic in the remaining two. Histological examination of frozen specimens confirmed the diagnosis of pleomorphic adenoma in all cases. All patients were treated according to the surgical technique described above, selecting a face-lift incision approach in all but one case, and preserving the posterior branch of the great auricular nerve. The duration of hospitalization ranged from 2 to 5 days (mean 3.4 days). Results
Follow-up ranged from 18 months to 11 years (mean 67.8 months) and the results of the surgery are summarized in Table 2. No major complications occurred. Minor complications included temporary facial nerve weakness in four patients that lasted for 2–6 weeks, and sialocele in another two patients, which was treated with drainage and daily dressing and resolved in 9
Table 2. Results of the surgery. Patient, sex and age
Complication
Male, 49 years
Temporary facial nerve (3 weeks) None None Sialocele (12 days) None Temporary facial nerve (2 weeks) Sialocele (9 days) None Temporary facial nerve (6 weeks) None Temporary facial nerve (2 weeks)
Female, 39 years Female, 48 years Male, 42 years Female, 41 years Female, 51 years Female, 40 years Male, 45 years Female, 44 years Male, 37 years Female, 35 years
Hospitalization
Follow-up (months)
Cosmesis: scar
Cosmesis: contour
Cosmesis: overall
weakness
5 days
131
Good
Excellent
Good
weakness
2 2 4 2 4
days days days days days
118 105 96 82 68
Excellent Excellent Excellent Good Excellent
Excellent Excellent Excellent Good Excellent
Excellent Excellent Excellent Good Excellent
weakness
5 days 3 days 5 days
53 39 27
Excellent Good Satisfactory
Excellent Excellent Satisfactory
Excellent Good Satisfactory
weakness
2 days 3 days
19 8
Excellent Excellent
Excellent Excellent
Excellent Excellent
Selective deep lobe parotidectomy and 12 days, respectively. No gustatory sweating (Frey’s syndrome) occurred and no cases of permanent facial nerve palsy or weakness were encountered. Despite the short follow-up period of some of the patients, which limited the oncologic evaluation, no recurrences were seen. Cosmetic results were assessed by the patients as poor, satisfactory, good, or excellent. The analyzed parameters were scar (satisfactory: 1, good: 3, excellent: 7), facial contour symmetry (satisfactory: 1, good: 1, excellent: 9), and overall result (satisfactory: 1, good: 3, excellent: 7). Case 1
A 39-year-old female patient (Fig. 1) was referred to our department with a swelling in the left parotid area of 2 year duration. US examination showed a 2.5-cm nonhomogeneous lesion set deep in the parotid gland and FNAB and MRI were performed. FNAB was consistent with pleomorphic adenoma and the MRI confirmed the presence of a 2.8-cm lesion suspected for a localization in the deep parotid lobe. After a preoperative general assessment, the patient underwent surgery consisting of the procedure described above: the superficial lobe was split and preserved (Fig. 2), the tumor was resected, and reconstruction of the parotid bed was performed (Fig. 3). After 2 days of uneventful hospitalization the patient was discharged. At follow-up evaluation at 118 months, no recurrence had occurred and the patient assessed the esthetic results
Fig. 1. Preoperative picture of patient 1.
Fig. 2. Intraoperative picture of patient 1 showing preservation and splitting of the superficial lobe, dissection of the inferior branches of the facial nerve, and deep lobe tumor exposure.
as excellent (for scar, facial contour symmetry, and overall cosmesis) (Fig. 4). Case 2
A 40-year-old female patient (Fig. 5) was referred after a diagnosis of pleomorphic adenoma of the right parotid gland based on FNAB and US performed at another hospital. A deep localization was suspected at US, so an MRI was performed and a deep lobe tumor extending to the parapharyngeal space measuring about 4.2 cm was detected (Fig. 6). The patient underwent surgery using a modified Redon incision: the superficial lobe was left attached anteriorly and completely elevated, thus exposing the deep lobe
1131
Fig. 3. Reconstruction of the parotid bed: the superficial lobe is repositioned and sutured to the sternocleidomastoid muscle flap.
including the tumor and mandible (Fig. 7); the dissection proceeded forward to the subcondylar area where a single mandibular osteotomy was performed to achieve a good exposure of the parapharyngeal space, and the tumor was resected. Mandibular osteosynthesis was performed with two titanium plates and the superficial lobe was repositioned to allow parotid bed reconstruction (Fig. 8). Two days after surgery the suction drain was removed and 2 days later the patient developed a sialocele, which was treated with daily drainage and dressing; the sialocele healed completely in 9 days. At 53 months of follow-up the patient was free from disease and assessed all the evaluated cosmesis parameters as excellent (Fig. 9).
Fig. 4. Postoperative picture of patient 1 in frontal (a) and lateral (b) view showing cosmetic results.
1132
Sesenna et al.
Fig. 6. Preoperative MRI in axial (a) and coronal (b) planes showing tumor extension to the parotid and para-pharynx.
Fig. 5. Preoperative picture of patient 2.
Discussion
The improvement in surgical techniques and the effectiveness of conservative procedures for the treatment of benign tumors of the parotid gland have led to a change in the primary goals of parotid surgery, which should include not only complete tumor resection, the prevention of recurrences, and preservation of facial nerve function, but also the achievement of satisfactory cosmetic results and a reduction in complications.10,11 In the past, the standard approach to a deep parotid lobe tumor consisted of a total or near total parotidectomy, with sacrifice of the superficial lobe and dissection of all the branches of the facial nerve. This led to several functional and esthetic disadvantages. Functionally, the complete dissection of the facial nerve increases the risk of temporary or permanent facial nerve weakness, as clearly demonstrated in various reviews of the results of superficial, total, and selective parotidectomies.12 Furthermore, resection of the superficial lobe, which makes up about 80% of the parenchymal tissue of the gland, leads to a reduction in gland function in terms of salivary secretion.13 Finally, it is well known that the incidence of gustatory sweating is closely related to the amount of glandular tissue resected. In this context, the selective deep lobe parotidectomy reduces facial nerve complications by limiting its dissection to only the branches in proximity to the tumor, preserving the function of the parotid gland and reducing the occurrence of
Fig. 7. Intraoperative picture of patient 2: the superficial lobe is entirely elevated and left pedicled anteriorly and the mandible and deep lobe tumor are exposed.
Fig. 8. Intraoperative picture showing parotid bed reconstruction.
Fig. 9. Postoperative picture of patient 2 in frontal (a) and lateral (b) view showing cosmetic results.
Selective deep lobe parotidectomy Frey’s syndrome, as unanimously described by the authors who have reported this technique. In the series of patients reported here, there were no cases of Frey’s syndrome confirmed by starch– iodine test and no cases of permanent facial nerve weakness. From an esthetic point of view, the selective deep lobe parotidectomy achieves satisfactory cosmetic results. Preservation of the superficial lobe reduces the surgical defect that is limited to the deep lobe (about 20% of the gland) and allows for complete reconstruction of the parotid bed, thus preventing depression in the preauricular area and deformation of the facial contour.14 The cosmetic results of our small series of patients confirm these findings: seven patients assessed their cosmetic outcome as excellent and three assessed it as good. The more controversial point of the procedure is its oncological safety. Previous reports on the partial parotidectomy clearly demonstrate its safety for the treatment of benign tumors of the superficial lobe, but few were considered deep lobe tumors.15 Despite the lack of randomized trials for deep lobe tumors, due to the rarity of this localization, all have reported no recurrence in patients treated with this technique. In our experience, and as described by other authors, in cases of tumor proximity to the facial nerve we usually remove further parotid tissue around the nerve, taking care to avoid neural damage. However, as in our series, some of the reported follow-ups were shorter than 10 years, making a definitive assessment of the safety of this approach difficult. Limited field exposure could be considered a drawback of this technique, but we encountered no technical difficulty and field exposure was adequate, making it unnecessary to sacrifice the superficial lobe simply to access the deep lobe, even when the parapharyngeal space was approached, as in case 2 reported here.16 The main contraindications are treatment for recurrences and, obviously, malignancies, for which a total parotidectomy is the treatment of the disease. With regard to the surgical technique, we sometimes elevate the entire superficial lobe in a single piece leaving it pedicled anteriorly and attached to the skin, dissecting all nerve branches; however, usually it is preferable to divide it more or less in the middle, dissecting only
the branches that are need to. In this way the dissection of the facial nerve branches is further reduced with adequate exposure of the tumor area. In conclusion, the partial/selective parotidectomy is an established technique in the treatment of benign tumors of the superficial parotid gland. The selective deep lobe parotidectomy is an extension of these principles to deep parotid lobe tumors and could represent an effective technique for their management. The reduction in complications such as facial nerve impairment and Frey’s syndrome, and especially the improvement in cosmesis are the major advantages of this procedure. Despite the encouraging oncological results, further trials with long-term follow-up periods should be performed to confirm these findings and to clearly demonstrate the ability of this method to prevent recurrence. Funding
None. Competing interests
None declared. Ethical approval
Not required. References 1. Leverstein H, van der Wal JE, Tiwari RM, van der Waal I, Snow GB. Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland. Br J Surg 1997;84:399–403. 2. Papadogeorgakis N. Partial superficial parotidectomy as the method of choice for treating pleomorphic adenomas of the parotid gland. Br J Oral Maxillofac Surg 2011;49:447–50. 3. O’Brien CJ. Current management of benign parotid tumors—the role of limited superficial parotidectomy. Head Neck 2003;25: 946–52. 4. Witt RL, Rejto L. Pleomorphic adenoma: extracapsular dissection versus partial superficial parotidectomy with facial nerve dissection. Del Med J 2009;81:119–25. 5. Johnson JT, Ferlito A, Fagan JJ, Bradley PJ, Rinaldo A. Role of limited parotidectomy in the management of pleomorphic adenoma. J Laryngol Otol 2007;121:1126–8.
1133
6. Hussain A, Murray DP. Preservation of the superficial lobe for deep-lobe parotid tumors: a better aesthetic outcome. Ear Nose Throat J 2005;84:518–24. 7. Avery CM, Fleming K, Siegmund CJ. Preservation of the superficial lobe with tumours of the deep-lobe of the parotid. Br J Oral Maxillofac Surg 2007;45:247–8. 8. Roh JL, Park CI. Function-preserving parotid surgery for benign tumors involving the deep parotid lobe. J Surg Oncol 2008;98: 42–5. 9. Zhang NS, Wei W, Sun JY. Parotidectomy of deep-lobe tumors. Zhonghua Er Bian Hou Tou Jing Wai Ke Za Zhi 2007;42:757–9. 10. Ciuman RR, Oels W, Jaussi R, Dost P. Outcome, general, and symptom-specific quality of life after various types of parotid resection. Laryngoscope 2012;122:1254–61. 11. Bozzetti A, Biglioli F, Salvato G, Brusati R. Technical refinements in surgical treatment of benign parotid tumours. J Craniomaxillofac Surg 1999;27:289–93. 12. Guntinas-Lichius O, Gabriel B, Klussmann JP. Risk of facial palsy and severe Frey’s syndrome after conservative parotidectomy for benign disease: analysis of 610 operations. Acta Otolaryngol 2006;126: 1104–9. 13. Colella G, Giudice A, Rambaldi P, Cuccurullo V. Parotid function after selective deep lobe parotidectomy. Br J Oral Maxillofac Surg 2007;45:108–11. 14. Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Improving esthetic results in benign parotid surgery: statistical evaluation of facelift approach, sternocleidomastoid flap, and superficial musculoaponeurotic system flap application. J Oral Maxillofac Surg 2011;69:1235–41. 15. Witt RL. The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 2002;112:2141–54. 16. Bianchi B, Ferri A, Ferrari S, Copelli C, Magri AS, Sesenna E. Single, subcondylar mandibular osteotomy: a new access route for extensive, benign parapharyngeal neoplasms. J Laryngol Otol 2010;124: 909–12.
Address: Andrea Ferri Maxillo-Facial Surgery Division Head and Neck Department University Hospital of Parma Via Gramsci 14 43100 Parma Italy Tel: +39 0521 703107/703109; Fax: +39 0521 703761 E-mail: [email protected]
Clinical Paper Clinical Pathology
Selective deep lobe parotidectomy for pleomorphic adenomas
E. Sesenna1, B. Bianchi1, S. Ferrari1, C. Copelli1, T. Ferri2, A. Ferri1 1 Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy; 2Otolaryngology Head Neck Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
E. Sesenna, B. Bianchi, S. Ferrari, C. Copelli, T. Ferri, A. Ferri: Selective deep lobe parotidectomy for pleomorphic adenomas. Int. J. Oral Maxillofac. Surg. 2013; 42: 1129–1133. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The authors’ experience of the selective deep lobe parotidectomy for the treatment of pleomorphic adenomas of the deep parotid lobe is presented. A retrospective analysis of 11 patients treated between 1997 and 2010 was performed; seven were males and four were females, ranging in age from 35 to 51 years. Parameters evaluated included facial nerve weakness, the occurrence of Frey’s syndrome, cosmetic outcome, and recurrence. Follow-up ranged from 18 months to 11 years. No major complications, permanent facial nerve weakness, or Frey’s syndrome occurred. Four patients developed temporary facial nerve impairments that lasted between 2 and 6 weeks, and two developed a sialocele that healed in 9 days in one case and 12 days in the other. The overall cosmetic assessment was excellent in eight patients, good in two, and satisfactory in the remaining one. No recurrences occurred. The selective deep lobe parotidectomy can be considered an effective technique for the management of deep parotid lobe pleomorphic adenomas. The major advantages of this procedure include a reduction in complications such as facial nerve impairments and Frey’s syndrome, and an improved cosmetic outcome.
Over the past three decades, the approach to parotid gland benign tumors has changed from superficial or total parotidectomies to partial/selective parotidectomies or extracapsular dissection.1 Despite the controversies in the international literature, a general agreement on the effectiveness of the partial parotidectomy approach is presently well established.2,3 Partial/selective parotidectomies allow complete and safe tumor removal, better functional outcomes, and a reduction in complications such as facial 0901-5027/0901129 + 05 $36.00/0
nerve impairment and Frey’s syndrome.4 Furthermore, the preservation of healthy parotid tissue allows reconstruction of the parotid bed and a reduction in facial contour deficiency, thus improving the cosmetic outcome.5 The principles of partial/selective parotidectomies have recently been extended by some authors to the management of deep parotid lobe benign tumors, shifting surgical treatment of these neoplasms from total or near total parotidectomies
Key words: parotid surgery; parotidectomy; deep lobe tumors; selective deep lobe parotidectomy. Accepted for publication 16 April 2013 Available online 20 May 2013
to selective deep lobe resections.6 This procedure preserves the superficial parotid lobe, ensuring better function and cosmesis, and reduces the complications associated with more extensive procedures.7 Despite the effectiveness of this technique, a complete literature review revealed only four papers on this topic.6–9 Authors present herein the authors’ experience of the selective deep lobe parotidectomy, discussing the surgical technique, indications, and results of this approach.
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1130
Sesenna et al. Table 1. Patients with deep parotid lobe pleomorphic adenomas treated with selective deep lobe parotidectomy.
Methods Surgical technique
Usually a standard face-lift incision is performed and a comprehensive flap of skin, subcutaneous tissue, and superficial musculo-aponeurotic system (SMAS) tissue is elevated. The flap is dissected less far forward than a standard superficial parotidectomy to preserve some vascularization to the superficial parotid lobe that will later be dissected. The great auricular nerve and its posterior branch are identified on the surface of the sternocleidomastoid muscle, dissected and preserved. The main trunk of the facial nerve is identified using classical landmarks and by electrostimulation, if needed, and is carefully dissected. The facial nerve division is identified and the superficial lobe of the parotid is elevated from behind, with dissection of the facial nerve branches. In seven cases, the superficial lobe was also split into two halves (superior and inferior) to achieve an easier and quicker approach to the deep lobe. The superficial lobe (in one or two pieces) is left pedicled anteriorly. Once the tumor is identified it is preferable to free completely (also in the deep surface) only those nerve branches that it is essential to dissect in order to achieve a complete and safe dissection of the tumor. In this way the tumor is dissected below the plane of the facial nerve and removed, if possible, with a cuff of healthy deep lobe glandular tissue. Then the superficial parotid lobe is repositioned and sutured to the pre-tragal tissues and to the sternocleidomastoid muscle with resorbable sutures, achieving a complete reconstruction of the parotid fascia. A suction drain is placed and the skin flap is repositioned and sutured by planes.
Patient, sex and age
Side
FNAB result
Imaging
Male, 49 years Female, 39 years Female, 48 years Male, 42 years Female, 41 years Female, 51 years Female, 40 years Male, 45 years Female, 44 years Male, 37 years Female, 35 years
Right Left Right Left Right Right Right Left Right Right Right
Pleomorphic adenoma Pleomorphic adenoma Non-diagnostic Pleomorphic adenoma Pleomorphic adenoma Pleomorphic adenoma Pleomorphic adenoma Non-diagnostic Pleomorphic adenoma Pleomorphic adenoma Pleomorphic adenoma
CT MRI MRI CT MRI MRI MRI MRI CT MRI MRI
FNAB, fine-needle aspiration biopsy; CT, computed tomography; MRI, magnetic resonance imaging.
Patients
From 1 January 1997 to 31 December 2010, 368 patients were treated for benign tumors affecting the parotid gland. A retrospective evaluation of the clinical data revealed 11 cases of deep parotid lobe pleomorphic adenoma treated with a selective deep lobe parotidectomy; these cases were included in the study. Patient data are summarized in Table 1. The study was granted exemption from institutional review board approval due its retrospective nature and was performed in compliance with the World Medical Association Declaration of Helsinki on medical research protocols and ethics. Seven patients were female and four male, ranging in age from 35 to 51 years (mean 42.8 years). The right parotid was involved in eight cases and the left in the remaining three. Preoperative assessment included ultrasound (US) and fine-needle aspiration biopsy (FNAB), followed by magnetic resonance imaging (MRI) or contrast enhanced computed tomography (CT) in
all cases (eight MRI and three CT). FNAB was diagnostic for pleomorphic adenoma in nine patients, but was non-diagnostic in the remaining two. Histological examination of frozen specimens confirmed the diagnosis of pleomorphic adenoma in all cases. All patients were treated according to the surgical technique described above, selecting a face-lift incision approach in all but one case, and preserving the posterior branch of the great auricular nerve. The duration of hospitalization ranged from 2 to 5 days (mean 3.4 days). Results
Follow-up ranged from 18 months to 11 years (mean 67.8 months) and the results of the surgery are summarized in Table 2. No major complications occurred. Minor complications included temporary facial nerve weakness in four patients that lasted for 2–6 weeks, and sialocele in another two patients, which was treated with drainage and daily dressing and resolved in 9
Table 2. Results of the surgery. Patient, sex and age
Complication
Male, 49 years
Temporary facial nerve (3 weeks) None None Sialocele (12 days) None Temporary facial nerve (2 weeks) Sialocele (9 days) None Temporary facial nerve (6 weeks) None Temporary facial nerve (2 weeks)
Female, 39 years Female, 48 years Male, 42 years Female, 41 years Female, 51 years Female, 40 years Male, 45 years Female, 44 years Male, 37 years Female, 35 years
Hospitalization
Follow-up (months)
Cosmesis: scar
Cosmesis: contour
Cosmesis: overall
weakness
5 days
131
Good
Excellent
Good
weakness
2 2 4 2 4
days days days days days
118 105 96 82 68
Excellent Excellent Excellent Good Excellent
Excellent Excellent Excellent Good Excellent
Excellent Excellent Excellent Good Excellent
weakness
5 days 3 days 5 days
53 39 27
Excellent Good Satisfactory
Excellent Excellent Satisfactory
Excellent Good Satisfactory
weakness
2 days 3 days
19 8
Excellent Excellent
Excellent Excellent
Excellent Excellent
Selective deep lobe parotidectomy and 12 days, respectively. No gustatory sweating (Frey’s syndrome) occurred and no cases of permanent facial nerve palsy or weakness were encountered. Despite the short follow-up period of some of the patients, which limited the oncologic evaluation, no recurrences were seen. Cosmetic results were assessed by the patients as poor, satisfactory, good, or excellent. The analyzed parameters were scar (satisfactory: 1, good: 3, excellent: 7), facial contour symmetry (satisfactory: 1, good: 1, excellent: 9), and overall result (satisfactory: 1, good: 3, excellent: 7). Case 1
A 39-year-old female patient (Fig. 1) was referred to our department with a swelling in the left parotid area of 2 year duration. US examination showed a 2.5-cm nonhomogeneous lesion set deep in the parotid gland and FNAB and MRI were performed. FNAB was consistent with pleomorphic adenoma and the MRI confirmed the presence of a 2.8-cm lesion suspected for a localization in the deep parotid lobe. After a preoperative general assessment, the patient underwent surgery consisting of the procedure described above: the superficial lobe was split and preserved (Fig. 2), the tumor was resected, and reconstruction of the parotid bed was performed (Fig. 3). After 2 days of uneventful hospitalization the patient was discharged. At follow-up evaluation at 118 months, no recurrence had occurred and the patient assessed the esthetic results
Fig. 1. Preoperative picture of patient 1.
Fig. 2. Intraoperative picture of patient 1 showing preservation and splitting of the superficial lobe, dissection of the inferior branches of the facial nerve, and deep lobe tumor exposure.
as excellent (for scar, facial contour symmetry, and overall cosmesis) (Fig. 4). Case 2
A 40-year-old female patient (Fig. 5) was referred after a diagnosis of pleomorphic adenoma of the right parotid gland based on FNAB and US performed at another hospital. A deep localization was suspected at US, so an MRI was performed and a deep lobe tumor extending to the parapharyngeal space measuring about 4.2 cm was detected (Fig. 6). The patient underwent surgery using a modified Redon incision: the superficial lobe was left attached anteriorly and completely elevated, thus exposing the deep lobe
1131
Fig. 3. Reconstruction of the parotid bed: the superficial lobe is repositioned and sutured to the sternocleidomastoid muscle flap.
including the tumor and mandible (Fig. 7); the dissection proceeded forward to the subcondylar area where a single mandibular osteotomy was performed to achieve a good exposure of the parapharyngeal space, and the tumor was resected. Mandibular osteosynthesis was performed with two titanium plates and the superficial lobe was repositioned to allow parotid bed reconstruction (Fig. 8). Two days after surgery the suction drain was removed and 2 days later the patient developed a sialocele, which was treated with daily drainage and dressing; the sialocele healed completely in 9 days. At 53 months of follow-up the patient was free from disease and assessed all the evaluated cosmesis parameters as excellent (Fig. 9).
Fig. 4. Postoperative picture of patient 1 in frontal (a) and lateral (b) view showing cosmetic results.
1132
Sesenna et al.
Fig. 6. Preoperative MRI in axial (a) and coronal (b) planes showing tumor extension to the parotid and para-pharynx.
Fig. 5. Preoperative picture of patient 2.
Discussion
The improvement in surgical techniques and the effectiveness of conservative procedures for the treatment of benign tumors of the parotid gland have led to a change in the primary goals of parotid surgery, which should include not only complete tumor resection, the prevention of recurrences, and preservation of facial nerve function, but also the achievement of satisfactory cosmetic results and a reduction in complications.10,11 In the past, the standard approach to a deep parotid lobe tumor consisted of a total or near total parotidectomy, with sacrifice of the superficial lobe and dissection of all the branches of the facial nerve. This led to several functional and esthetic disadvantages. Functionally, the complete dissection of the facial nerve increases the risk of temporary or permanent facial nerve weakness, as clearly demonstrated in various reviews of the results of superficial, total, and selective parotidectomies.12 Furthermore, resection of the superficial lobe, which makes up about 80% of the parenchymal tissue of the gland, leads to a reduction in gland function in terms of salivary secretion.13 Finally, it is well known that the incidence of gustatory sweating is closely related to the amount of glandular tissue resected. In this context, the selective deep lobe parotidectomy reduces facial nerve complications by limiting its dissection to only the branches in proximity to the tumor, preserving the function of the parotid gland and reducing the occurrence of
Fig. 7. Intraoperative picture of patient 2: the superficial lobe is entirely elevated and left pedicled anteriorly and the mandible and deep lobe tumor are exposed.
Fig. 8. Intraoperative picture showing parotid bed reconstruction.
Fig. 9. Postoperative picture of patient 2 in frontal (a) and lateral (b) view showing cosmetic results.
Selective deep lobe parotidectomy Frey’s syndrome, as unanimously described by the authors who have reported this technique. In the series of patients reported here, there were no cases of Frey’s syndrome confirmed by starch– iodine test and no cases of permanent facial nerve weakness. From an esthetic point of view, the selective deep lobe parotidectomy achieves satisfactory cosmetic results. Preservation of the superficial lobe reduces the surgical defect that is limited to the deep lobe (about 20% of the gland) and allows for complete reconstruction of the parotid bed, thus preventing depression in the preauricular area and deformation of the facial contour.14 The cosmetic results of our small series of patients confirm these findings: seven patients assessed their cosmetic outcome as excellent and three assessed it as good. The more controversial point of the procedure is its oncological safety. Previous reports on the partial parotidectomy clearly demonstrate its safety for the treatment of benign tumors of the superficial lobe, but few were considered deep lobe tumors.15 Despite the lack of randomized trials for deep lobe tumors, due to the rarity of this localization, all have reported no recurrence in patients treated with this technique. In our experience, and as described by other authors, in cases of tumor proximity to the facial nerve we usually remove further parotid tissue around the nerve, taking care to avoid neural damage. However, as in our series, some of the reported follow-ups were shorter than 10 years, making a definitive assessment of the safety of this approach difficult. Limited field exposure could be considered a drawback of this technique, but we encountered no technical difficulty and field exposure was adequate, making it unnecessary to sacrifice the superficial lobe simply to access the deep lobe, even when the parapharyngeal space was approached, as in case 2 reported here.16 The main contraindications are treatment for recurrences and, obviously, malignancies, for which a total parotidectomy is the treatment of the disease. With regard to the surgical technique, we sometimes elevate the entire superficial lobe in a single piece leaving it pedicled anteriorly and attached to the skin, dissecting all nerve branches; however, usually it is preferable to divide it more or less in the middle, dissecting only
the branches that are need to. In this way the dissection of the facial nerve branches is further reduced with adequate exposure of the tumor area. In conclusion, the partial/selective parotidectomy is an established technique in the treatment of benign tumors of the superficial parotid gland. The selective deep lobe parotidectomy is an extension of these principles to deep parotid lobe tumors and could represent an effective technique for their management. The reduction in complications such as facial nerve impairment and Frey’s syndrome, and especially the improvement in cosmesis are the major advantages of this procedure. Despite the encouraging oncological results, further trials with long-term follow-up periods should be performed to confirm these findings and to clearly demonstrate the ability of this method to prevent recurrence. Funding
None. Competing interests
None declared. Ethical approval
Not required. References 1. Leverstein H, van der Wal JE, Tiwari RM, van der Waal I, Snow GB. Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland. Br J Surg 1997;84:399–403. 2. Papadogeorgakis N. Partial superficial parotidectomy as the method of choice for treating pleomorphic adenomas of the parotid gland. Br J Oral Maxillofac Surg 2011;49:447–50. 3. O’Brien CJ. Current management of benign parotid tumors—the role of limited superficial parotidectomy. Head Neck 2003;25: 946–52. 4. Witt RL, Rejto L. Pleomorphic adenoma: extracapsular dissection versus partial superficial parotidectomy with facial nerve dissection. Del Med J 2009;81:119–25. 5. Johnson JT, Ferlito A, Fagan JJ, Bradley PJ, Rinaldo A. Role of limited parotidectomy in the management of pleomorphic adenoma. J Laryngol Otol 2007;121:1126–8.
1133
6. Hussain A, Murray DP. Preservation of the superficial lobe for deep-lobe parotid tumors: a better aesthetic outcome. Ear Nose Throat J 2005;84:518–24. 7. Avery CM, Fleming K, Siegmund CJ. Preservation of the superficial lobe with tumours of the deep-lobe of the parotid. Br J Oral Maxillofac Surg 2007;45:247–8. 8. Roh JL, Park CI. Function-preserving parotid surgery for benign tumors involving the deep parotid lobe. J Surg Oncol 2008;98: 42–5. 9. Zhang NS, Wei W, Sun JY. Parotidectomy of deep-lobe tumors. Zhonghua Er Bian Hou Tou Jing Wai Ke Za Zhi 2007;42:757–9. 10. Ciuman RR, Oels W, Jaussi R, Dost P. Outcome, general, and symptom-specific quality of life after various types of parotid resection. Laryngoscope 2012;122:1254–61. 11. Bozzetti A, Biglioli F, Salvato G, Brusati R. Technical refinements in surgical treatment of benign parotid tumours. J Craniomaxillofac Surg 1999;27:289–93. 12. Guntinas-Lichius O, Gabriel B, Klussmann JP. Risk of facial palsy and severe Frey’s syndrome after conservative parotidectomy for benign disease: analysis of 610 operations. Acta Otolaryngol 2006;126: 1104–9. 13. Colella G, Giudice A, Rambaldi P, Cuccurullo V. Parotid function after selective deep lobe parotidectomy. Br J Oral Maxillofac Surg 2007;45:108–11. 14. Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Improving esthetic results in benign parotid surgery: statistical evaluation of facelift approach, sternocleidomastoid flap, and superficial musculoaponeurotic system flap application. J Oral Maxillofac Surg 2011;69:1235–41. 15. Witt RL. The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 2002;112:2141–54. 16. Bianchi B, Ferri A, Ferrari S, Copelli C, Magri AS, Sesenna E. Single, subcondylar mandibular osteotomy: a new access route for extensive, benign parapharyngeal neoplasms. J Laryngol Otol 2010;124: 909–12.
Address: Andrea Ferri Maxillo-Facial Surgery Division Head and Neck Department University Hospital of Parma Via Gramsci 14 43100 Parma Italy Tel: +39 0521 703107/703109; Fax: +39 0521 703761 E-mail: [email protected]