Parotidectomy for bulimia: A dissenting view

Am J Otolaryn8ol 8:376--3S0, 1987

Parotidectomy for Bulimia: A Dissenting View STEVEN D. RAUCH, MD* AND DAVID B. I-tERZOG, MDt Bulimia nervosa is an eating disorder syndrome characterized by frequent binge-eating episodes followed by self-induced vomiting, fasting, excessive exercise, or the use of laxatives or diuretics. In addition to the psychological manifestations of this disorder, the patient may exhibit an array of physical symptoms. The major otolaryngologic finding is the presence of benign, persistent enlargement of the parotid and/or submandibular salivary glands in some patients with more severe bingeing and purging behavior. Recent reports in the otolaryngology literature have advocated superficial parotidectomy for correction of the cosmetic deformity of this sialadenomegaly. A detailed description of the psychological and behavioral manifestations and natural history of this illness is presented. The authors believe that surgical management of parotid enlargement in patients with bulimia nervosa is contraindicated by the surgical risks, the natural history of the disorder, and the patient's psychological state,

Since initially reported by Lavender, 1 there has been an increasing number of reports of parotid and submandibular salivary gland enlargement in association with bulimia or bulimia-like symptoms. 2-7 Bulimia, soon to be referred to as bulimia nervosa, is a syndrome characterized by frequent binge-eating episodes that are followed by self-induced vomiting, fasting, excessive exercise, or the use of laxatives or diuretics. The b u l i m i c patient is t y p i c a l l y a y o u n g adult, middle-class white woman who has attempted various diets without much success. Either accidentally or through a friend or family member, the bulimic becomes aware of self-induced vomiting or laxative use as a method of weight management. She often binges on junk food and sets aside time each day to binge alone. After eating, she feels out of control and reports feelings of guilt, shame, and low self esteem. She is embarrassed by her food-related s y m p t o m s and is often unable to tell others, including her family, friends, spouse, or physician. The eating behaviors and preoccupation with food frequently interfere with work, relationships, and activities. Depression in bulimia nervosa is common.

Received March 18, 1987, from the Departments of *Otology and Laryngology and ~Psychiatry, Harvard Medical School at the Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Accepted for publication May 28, 1987. Address reprint requests to Dr. Rauch: Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. 0196-0709/87 $0.00 + .25

One study reported that 59 (80%) of 74 bulimics had lifetime histories of major affective disorder. 8 B u l i m i c s e x h i b i t a v a r i e t y of p h y s i c a l symptoms of their disorder. They often have irregular menstrual cycles and, in some cases, are amenorrheic. They may develop complications, such as hypocalcemia, rectal bleeding, destruction of dental enamel, and parotid and submandibular salivary gland enlargement. Current theories regarding the etiologies of these complications have been well described. ~,7 Reports on the f r e q u e n c y of b u l i m i a n e r v o s a have varied. A retrospective study of 500 students presenting to a university psychiatric clinic and diagnosed in accordance with the third edition Diagnostic and Statistical Manual (DSM III) of the American Psychiatric Association criteria found that 3.8% of the total sample and 5.4% of the women sampled had bulimia nervosa. 9 As additional cases of the disorder were diagnosed during therapy, the investigators concluded that their findings represented a conservative estimate of the prevalence of bulimia nervosa in the clinic population. In the largest survey to date, Pyle et al. 1~ reported that 7.8% of women and 1.4% of m e n in a sample of 1,355 freshman students (98% r e s p o n s e rate) were bulimic. A survey of a small liberal arts college found that 13% of the respondents met the DSM III criteria for bulimia nervosa. 11 In a study of 300 female shoppers w h o r e s p o n d e d to a questionnaire, 10.3% reported lifetime histories of bulimia ner-

376

R A U C H AND H E R Z O G

vosafl 2 In a recent medical school survey we found that nearly 12% of female students had a history of bulimia nervosa. These data support the belief that the disorder is widespread and increasing in prevalence. Recent reports have appeared in the otolaryngology literature advocating superficial parotidectomy for the management of bulimic sialadenomegaly. 2,4 In light of the data indicating an increasing prevalence of the disorder and the resultant increase in the likelihood of the involvement of the otolaryngologist in the evaluation and management of these patients, we think it is essential to present a detailed description of the p s y c h o l o g i c a l and behavioral manifestations and natural history of this illness. We believe that surgical management of parotid enlargement in patients with bulimia nervosa is contraindicated by the surgical risks, the natural history of the disorder, and the patients' psychological states. NATURAL HISTORY Follow-up studies of patients with bulimia n e r v o s a first a p p e a r e d in the literature in 1983.13,~4 T h e s e s t u d i e s d e s c r i b e d w i d e l y varying rates of recovery from bulimia, from a l o w of 13% after 2 to 5 years of follow-up to a high of 71% after 2 years of follow-up. The Massachusetts General Hospital Eating Disorders Unit recently completed a 1-year prospective longitudinal study on the course of bulimia as well as the course of depression (because of its high comorbid rate). We were able to gather data based on 52 weeks of follow-up on 29 of the 30 bulimic subjects. Although one subject was not available for interview at 1 year, data from her 6-month follow-up was included in the analysis. In that study, the bulimic subjects were recruited from a consecutive sampling of patients w h o sought emergency treatment at the Massachusetts General Hospital. The mean age of the 30 subjects was 23.9 years. The mean duration of the index episode of bulimia nervosa was 5.03 _-+ 3.1 years. Twenty-five (83%) of the 30 women had lifetime histories of affective illness, and 57% met criteria for affective disorder at intake. At 1 year, the cumulative probability of recovery from the bulimia nervosa was 54%, and the median time to recovery was 12 weeks. The cumulative probability of recovery from the affective disorder was 46%, and the median time to recovery was 10 weeks. Of the 17 subjects with an affective disorder at intake, five (29%) recovered from both the index episode of bulimia nervosa

and the index episode of affective disorder during the 52 weeks of follow-up. Study subjects were required to be well for 8 consecutive weeks to be considered recovered. Based on Kaplan-Meier estimates of the probabilities that a subject will remain well through week T at risk, about one fourth of the subjects who recover from the bulimia nervosa within the first year will relapse within 18 weeks at risk, and 50% will relapse within 44 weeks at risk. Furthermore, three (37%) of eight subjects who recovered from the index affective disorder relapsed into new affective disorder during the follow-up interval. It should be noted that the bulimic patients received the usual treatments prescribed in our unit, including some combination of individual, group, family, and pharmacotherapy. Because at this time there is no "effective" treatment for bulimia, the rates of outcome in this study were thought to approximate the true course of bulimia nervosa and affective disorder in bulimic patients. The results of this study show that the short-term course of bulimia nervosa is characterized by frequent relapses and a high comorbidity of major affective illness. Furthermore, the frequency of short-term remissions suggests that the results of short-term treatment trials be interpreted with caution until the patients are demonstrated to sustain the positive response. PATHOGENESIS OF BULIMIA The pathogenesis of bulimia nervosa must take into account the sociocultural, psychological, and biologic perspectives. There is little doubt that the cultural value placed on thinness in Western society plays an important part in the development of this disorder. As compared to other psychosomatic disorders, there is general agreement about the presence of psychological dysfunction in eating disorders. Bulimics have distorted attitudes and concepts that affect almost every area of their lives, including perfectionism and the belief that weight gain means one is "bad" or "out of control." Ego psychologists propose an ego defect as the central causative factor. Some have asserted that bulimic patients lack the ego function of object constancy; when separated from the symbiotic mother, they are unable to evoke a mental representation of the soothing mother and, consequently, use binge-eating as a means of evoking that earlier representation, is Regarding the biologic factors, studies of bulimia suggest possible central neuVolume 8 rochemical abnormalities of the serotonergic Number 6 and noradrenergic systems. 7 Increased serotonin November 1987 377

PAROTIDECTOMY FOR BULIMIA

synthesis can reduce appetite, especially for carbohydrates. 16 The noradrenergic system has been implicated only indirectly. Imipramine, shown to be effective in reducing hinging behavior in same bulimic patients, is a potent norepinephrine reuptake blocker. 12 PATHOGENESIS OF BULIMIC SIALADENOMEGALY

American Journal of Otolaryngology 378

The pathophysiology of bulimic sialadenomegaly is u n k n o w n . Similar to the report by Brady, 3 we have observed an incidence of intermittent parotid swelling of approximately 10% of the last 1,200 consecutive presenting bulimics. This intermittent form of the sialadenomegaly occurs primarily in those patients vomiting one or more times daily. Only five of the 1,200 patients suffered persistent disfiguring pafetid enlargement as in the cases reported by Berke and Calcaterra, 2 Brady, ~ and Burke. 4 These five patients were referred to the Otolaryngology Department of the Massachusetts Eye and Ear Infirmary for evaluation of their sialadenomegaly. All five patients reported vomiting at least one to three times daily. Furthermore, all reported increases in gland size, firmness, and associated discomfort as they increased the time interval between vomiting episodes during efforts to reduce their disordered eating behaviors. This firmness and discomfort was relieved by vomiting. In none of the five did the gland size diminish during remissions of binging behavior lasting up to 3 months. None of the five patients complained of xerostomia or sialorrhea. All had good dentition, with none of the severe caries and enamel loss occasionally seen in bulimia. Metabolic evaluation of patients with this disorder was carried out exhaustively in the study by Levin et el. ~ and revealed occasional metabolic alkalosis and elevated serum amylase. All of our patients had assessment of metabolic status as part of the routine medical evaluation carried out at the time of intake. These metabolic variables were not reevaluated at the time of otolaryngology referral. Review of roentgenograms of the two patients who had undergone sialography prior to intake revealed normal ductal structures with no evidence of obstruction, dilatation, or other distortion. One of these patients had also undergone computed tomography scanning, which showed bilateral diffuse enlargement of the parotid glands. Parotid gland biopsy was done in one patient and revealed normal acini and gland architecture. There was no evidence of fatty or lymphocytic infiltrate,

degenerative changes, atretic or hyperplastic parenchyma, or change in the relative amounts of stroma and parenchyma. A variety of dietary and endocrine mediators of parotid secretion has been described. 17 It is unknown which, if any, of these mediators are involved in bulimic sialadenomegaly. An autonomic discharge associated with emesis is responsible for the gush of saliva that precedes vomiting. Probably the benign salivary gland enlargement of bulimic sialadenomegaly represents a physiologic response to the repeated secretory stimuli triggered by the frequent episodes of self-induced vomiting, socalled work hypertrophy. TREATMENT

It is useful in the treatment of bulimia to view the disorder as a compromise solution to psychological dilemmas. The initial task in therapy is to establish trust through the therapist's acknowledgment of the patient's ongoing pain and recognition of the multiple determinants of the disorder (social, psychopathologic, genetic, biochemical, behavioral, and familial). Modifying the eating behavior is the single defined goal w h e n the patient functions well in other respects and is prepared to withstand the consequences of change. In such cases a prescription for cognitive, behavioral, and/or psychopharmacologic treatment is adequate. Far more often, the patients presenting to the Eating Disorders Unit (who run the spectrum of severity of eating disorders) require a therapeutic relationship over an extended period to use group, family, behavioral, or biologic treatments. 18 Sometimes we need to reassure the fragile p a t i e n t - - w h o s e limited repertoire of c o p i n g skills leaves her d e p e n d e n t on the bingeing and p u r g i n g - - t h a t her bulimic behaviors will be allowed to remain while she begins to develop other compensatory strategies. Treatment of the patient with a severe character disorder who has fled previous treatment as a part of a lifelong pattern of unsustained relationships requires that the psychotherapist be able to proceed very slowly. An additional role for psychotherapeutic techniques in the care of patients with eating disorders is to help manage the intense counter-transference reactions that the patients frequently evoke through their hostility, rejection of help, neediness, relapsing symptoms, medical complications, and suicidal tendencies. Few psychiatric conditions require more farebearance and self questioning on the part of the treating psychiatrist.

RAUCH AND HERZOG

SURGICAL DECISION MAKING

The American Society of Plastic and Reconstructive Surgeons defines cosmetic surgery as follows: "Cosmetic surgery shall be defined as that surgery which is done to review or change the texture, configuration, or relationship with c o n t i g u o u s structures of any feature of the h u m a n body which would be considered by the average prudent observer to be within the broad range of "normal" and acceptable variation for age and ethnic origin, and in addition is performed for a condition which is judged by competent medical opinion to be without potential for jeopardy to physical or mental health. ''19 According to this definition, one may classify parotidectomy for bulimic sialadenomegaly as a cosmetic procedure, although the determination of the "broad range of normal" and "jeopardy to mental health" are difficult to assess. Parotidect o m y cannot he justified for strictly medical reasons. There are no data to suggest that the salivary gland enlargement of this disorder increases risk of any sequelae such as infection, neoplastic transformation, or loss of normal salivary gland function. In fact, the natural history of the glandular enlargement left untreated is unknown. Current formulations of the pathogenesis of bulimia place body-image distortion among an array of distorted attitudes and concepts affecting most areas of the bulimic's life. Therefore, a patient's distress over her perceived facial distortion is but one manifestation of her illness, not a cause, and may be far out of proportion to the severity of facial alteration as perceived by an observer. In those instances where obvious severe cosmetic deformity exists because of massive enlargement of the parotid glands, the patient's perfectionism, dichotomous thinking, and poor tolerance of frustration make her expectations for surgical correction unrealistically high and her chance of satisfaction low. Successful correction of the disfigurement might be expected to provide only brief "symptomatic" relief engendered by the elimination of a superficial manifestation of the underlying psychological disorder without any direct i m p r o v e m e n t in the psychopathology, while unnecessarily exposing her to the potential complications of surgery, including permanent facial disfigurement from scarring or facial nerve injury. The two cases of parotidectomy for bulimic sialadenomegaly reported by Berke and Calcaterra 2 and Burke 3 allude to early patient satisfaction with the outcome of surgery but give

information regarding long-term satisfaction or psychological impact. Numerous books and articles have dealt with the issue of appearance-altering surgery and the psychologically disturbed patient. Sound surgical practice dictates avoidance of elective appearance-altering operations in patients with a variety of preoperative behaviors and/or personality t y p e s - - i n c l u d i n g demanding, perfectionist, depressed, narcissistic, borderline, and dependent patients or those with unrealistic expectations or bizarre symbolic significance attached to the surgery--because of the well-documented increased likelihood of patient dissatisfaction, psychological turmoil, and litigation, ag-2z All these traits may be present in the personality constellation of the bulimic.

rm

SUMMARY

It is likely that otolaryngologists will see an increasing number of patients with bulimia. There may be strong pressure exerted by the patient, and even the referring physician, to relieve her anguish over facial distortion by performing a parotidectomy. We believe that the natural history of the eating disorder, the frequent co-occurrence of depression, the surgical risks, and the absence of any demonstrable medical benefit from the procedure are compelling reasons not to operate.

References 1, Lavender S: Vomiting and parotid enlargement. Lancet 1969;1:426 2. Berke GS, Calcaterra TC: Parotid hypertrophy with bulimia: A report of surgical management. Laryngoscope 1985;95(5):597-598 3. Brady JP: Parotid enlargement in bulimia. J Fam Prac 1985;20(5):496-502 4. Burke RC: Bulimia and parotid enlargement--Case report and treatment. ] Otolaryngol 1986;15(1):49-51 5. Levin PA, Falko JM, Dixon K, et aI: Benign parotid enlargement in bulimia. Ann Intern Med 1980;93:827829 6. Welsh TB, Croft CB, Katz JL: Anorexia nervosa and salivary gland enlargement. Int J Psychiatry Med 1981; 11[3):255-261 7. Herzog DB, Copeland PM: Eating disorders. N Engl J Med 1985;313(5):295-303 8. Hudson JI, Pope HG, Jonas JM, eta]: Phenomenologic relationship of eating disorders to major effective disorder. Psychiatry Res 1983:9:345-354 9. Stangler R8, Printz AM: DSM-III: Psychiatric diagnosis in a university population. Am J Psychiatry 1980;137: 937-940 10. Pyle RL, Mitchell IE, Eckert ED, et al: The incidence of bulimia in freshman college students. Int J Eat Disord 1983;2(3):75-85 Volume 8 11. Halmia KA, Falk JR, Schwartz E: Binge-eating and vomiting: A survey of a college population. Psychol Med Number 6 1981;11:697-706 November 1987 379

PAROTIDECTOMY FOR BULIMIA 12. Pope HG, Hudson J[, Yurgelum-Todd D: Anorexia norrosa and bulimia among 309 women shoppers. Am j" Psychiatry 1984;141:292-294 13. Abraham SF, Mira M, Llewellyn-Jones D: Bulimia: A study of outcome. Int J Eat Disord 1983;2:59-65 14. Lacey ]H: Bulimia nervosa, binge eating and psychogenic vomiting: A controlled treatment study and long-term outcome. Br J Psychiatry 1983;286:16091613 15. Swift W], Letven R: Bulimia and the basic fault'. A psychoanalytic interpretation of the binging-vomiting syndrome. ] Am Acad Child Psych 1984;23:489-497 16. Wurtman RJ: Behavioral effects of nutrients. Lancet 1983;1:1145-1147 17. Gill G: Metabolic and endocrine influences on the sali-

American Journal of Otolaryngology 3BO

18. 19. 20. 21. 22.

vary glands. Otolaryngol Clin North Am 1977; 10(2}:363-369 Herzog DB, Hamburg PA, Brotmav~ AW: Psychotherapy and eating disorders: A dissenting view. In press, Int J Eat Disord Goldwyn RM: The Patient and the Plastic Surgeon. New York, Little, Brown, 1981, pp 32-35 Courtiss EH: Aesthetic Surgery. St. Louis, CV Mosby, 1978, Ch 1-3 Goin JM, Goin MK: Changing the Body: Psychological Effects of Plastic Surgery. Baltimore, Williams and Wilkins, 1981. Ch 4-7 Goldwyn RM: The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. New York, Little, Brown, 1984, pp 3-14