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Parotidectomy versus limited resection for benign parotid masses
Parotidectomy Versus Limited Resection for Benign Parotid Masses John E. Woods, MD, Rochester,Minnesota
Despite the fact that parotidectomy has been well established as the appropriate treatment for benign •and many low grade malignant tumors of the parotid gland [1], tumor enucleation continues to be reported in the contemporary literature. In three recent publications, enucleation procedures were followed by recurrence rates of 42, 25, and 13.6 percent [2-4], whereas recurrences after parotidectomy in two of the series were 0 and 5 percent. Other researchers have advocated enucleation and radiation therapy as the treatment of choice because of the risk of facial nerve injury with parotidectomy [5]. In a series in which this practice was followed in the treatment of 73 benign tumors, two recurrences and four cases of permanent and mild facial nerve weakness were reported [6]. Since I believe that parotidectomy is the preferred treatment for benign tumors of the parotid gland, I report my personal experience with this procedure herein.
Material and Methods The histories of all patients who underwent parotidectomy for benign parotid masses between 1970 and 1978 were revievJed. Those who underwent the procedure for sialadenitis, malignancy, or prophylaxis were excluded. In patients with mixed tumors, only those in whom verified 5 year follow-updata were available were included. A total of 86 patients were eligiblefor the study. Fifty-fivepatients bed pleomorphic adenomas (benign mixed tumors), 14 had papillary cystadenoma lyrnphomatosum (Warthin's tumors), and the remaining 17 patients had other conditions, including hyperplastic lymph nodes, lipomas, benign lymphoepithelial lesions, and sarcoids. The procedure used in every instance but one was superficial parotidectomywith identification and preservation of.~ facial nerve branches as previouslydescribed [7]. In one patient, the procedure was extended to total conservative (nerve sparing) parotidectomy. From the Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota. Requests for reprints shouldbe addressedto John E. Woods, MD, Mayo Clinic, 200 First Street SW, Rochester,Minnesota 55905.
Volume 149, June 198$
Results In no patient was there recurrence nor was there permanent facial nerve weakness, although numbness of the ear was common. The most common complication was early mild (32 patients) or moderate (6 patients) facial nerve weakness, which was looked for carefully in all patients and recorded even when minimal and difficult to detect. Resolution usually occurred within a few days or weeks. Minor wound collections occurred in three patients and hematoma in one, with suture reaction and gustatory sweating occurring in one and three patients, respectively. One additional patient had transient intraoral drainage of purulent material through Stensen's duct. Three patients had two complications. Thus, there were 47 complications in 44 patients. All but a few were minimal and of short duration and required no treatment except drainage in the instances of wound collection or hematoma.
Comments In thismodest seriesof 86 patientswho underwent parotidectomy for benign disease with 5 to 13 year follow-up, no patient had either recurrence or permanent facialparalysis.The high complication rate recorded was overwhelmingly in the form of transient and minimal facialnerve weakness. This rather high incidencemay wellbe because there was an assiduous attempt to be totally accurate in recording even minimal weakness apparent only on vigorous facial muscular contracture.All patients subsequently recovered fullfunction. Thus, there were no complications of serious Consequence, and hospitalization was prolonged in only one instance. This experience with respect to the facialnerve is further born out by a much largernumber of parotidectomies (more than 300), including those for prophylaxis in malignant melanoma and squamous cellcarcinoma, as well as for therapeutic resections for metastatic disease and for primary parotid malignancies where sparing of the facialnerve was
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Woods
possible. In that larger series, which included the experience of residents assisted by me, permanent injury to a single branch (the mandibular) occurred in only one patient, which bears witness to the safety of the procedure when performed appropriately. Furthermore, with experience, superficial parotidectomy may generally be performed in 30 to 40 minutes with additional time for wound closure. In light of the results reported in this series and by others [8], to administer radiation therapy and enucleation seems inappropriate. Such an approach subjects the patient not only to the possible hazards of radiation in addition to the time and morbidity involved, but also increases the chance of facial nerve injury, which is always a possibility when random excision of parotid tissue is carried out.
Summary Parotidectomy for benign parotid masses in 86 patients has been reviewed. Morbidity, although common, was mild and transient. Recurrence and
750
permanent facial nerve weakness did not occur in any patient with 5 to 13 year follow-up. Superficial and conservative parotidectomies remain the procedures of choice for most benign tumor masses.
References 1. Beahrs OH. Parotld tumors and their surgical management. Am Surg 1957;23:891-9. 2. Dykun RJ, Deltel M, Borowy ZJ, Jackson S. Treatment of parotld neoplasms. Can J Sur9 1980;23:14-9. 3. Hughes RG, Lyons TJ. Parotld tumours, Lancet 1982;1:1080. 4. McEvedy BV, Ross WM. The treatment of mixed parotid tumours by enucleation end radiotherapy. Br J Surg 1976;63:3412, 5. McEvedy BV. Treatment of pteomorphlc adenomas by formal parotidectomy. Br J Surg 1982;69:237, 6. Stea G. Conservativesurgical treatmer~tof mixed turnouts of the parotld gland. J Maxlllofac Surg 1975;3:135-7. 7. Stevens KL, Hobsley M. The treatment of pleomorphlc adenomas by formal parotldectomy. Br J Surg 1982;69:1-3. 8. Woods JE. Parottdectomy: points of technique for brief and safe operation. Am J Surg 1983;145:678-83.
The Amedcan Journalof Surgery
Despite the fact that parotidectomy has been well established as the appropriate treatment for benign •and many low grade malignant tumors of the parotid gland [1], tumor enucleation continues to be reported in the contemporary literature. In three recent publications, enucleation procedures were followed by recurrence rates of 42, 25, and 13.6 percent [2-4], whereas recurrences after parotidectomy in two of the series were 0 and 5 percent. Other researchers have advocated enucleation and radiation therapy as the treatment of choice because of the risk of facial nerve injury with parotidectomy [5]. In a series in which this practice was followed in the treatment of 73 benign tumors, two recurrences and four cases of permanent and mild facial nerve weakness were reported [6]. Since I believe that parotidectomy is the preferred treatment for benign tumors of the parotid gland, I report my personal experience with this procedure herein.
Material and Methods The histories of all patients who underwent parotidectomy for benign parotid masses between 1970 and 1978 were revievJed. Those who underwent the procedure for sialadenitis, malignancy, or prophylaxis were excluded. In patients with mixed tumors, only those in whom verified 5 year follow-updata were available were included. A total of 86 patients were eligiblefor the study. Fifty-fivepatients bed pleomorphic adenomas (benign mixed tumors), 14 had papillary cystadenoma lyrnphomatosum (Warthin's tumors), and the remaining 17 patients had other conditions, including hyperplastic lymph nodes, lipomas, benign lymphoepithelial lesions, and sarcoids. The procedure used in every instance but one was superficial parotidectomywith identification and preservation of.~ facial nerve branches as previouslydescribed [7]. In one patient, the procedure was extended to total conservative (nerve sparing) parotidectomy. From the Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota. Requests for reprints shouldbe addressedto John E. Woods, MD, Mayo Clinic, 200 First Street SW, Rochester,Minnesota 55905.
Volume 149, June 198$
Results In no patient was there recurrence nor was there permanent facial nerve weakness, although numbness of the ear was common. The most common complication was early mild (32 patients) or moderate (6 patients) facial nerve weakness, which was looked for carefully in all patients and recorded even when minimal and difficult to detect. Resolution usually occurred within a few days or weeks. Minor wound collections occurred in three patients and hematoma in one, with suture reaction and gustatory sweating occurring in one and three patients, respectively. One additional patient had transient intraoral drainage of purulent material through Stensen's duct. Three patients had two complications. Thus, there were 47 complications in 44 patients. All but a few were minimal and of short duration and required no treatment except drainage in the instances of wound collection or hematoma.
Comments In thismodest seriesof 86 patientswho underwent parotidectomy for benign disease with 5 to 13 year follow-up, no patient had either recurrence or permanent facialparalysis.The high complication rate recorded was overwhelmingly in the form of transient and minimal facialnerve weakness. This rather high incidencemay wellbe because there was an assiduous attempt to be totally accurate in recording even minimal weakness apparent only on vigorous facial muscular contracture.All patients subsequently recovered fullfunction. Thus, there were no complications of serious Consequence, and hospitalization was prolonged in only one instance. This experience with respect to the facialnerve is further born out by a much largernumber of parotidectomies (more than 300), including those for prophylaxis in malignant melanoma and squamous cellcarcinoma, as well as for therapeutic resections for metastatic disease and for primary parotid malignancies where sparing of the facialnerve was
749
Woods
possible. In that larger series, which included the experience of residents assisted by me, permanent injury to a single branch (the mandibular) occurred in only one patient, which bears witness to the safety of the procedure when performed appropriately. Furthermore, with experience, superficial parotidectomy may generally be performed in 30 to 40 minutes with additional time for wound closure. In light of the results reported in this series and by others [8], to administer radiation therapy and enucleation seems inappropriate. Such an approach subjects the patient not only to the possible hazards of radiation in addition to the time and morbidity involved, but also increases the chance of facial nerve injury, which is always a possibility when random excision of parotid tissue is carried out.
Summary Parotidectomy for benign parotid masses in 86 patients has been reviewed. Morbidity, although common, was mild and transient. Recurrence and
750
permanent facial nerve weakness did not occur in any patient with 5 to 13 year follow-up. Superficial and conservative parotidectomies remain the procedures of choice for most benign tumor masses.
References 1. Beahrs OH. Parotld tumors and their surgical management. Am Surg 1957;23:891-9. 2. Dykun RJ, Deltel M, Borowy ZJ, Jackson S. Treatment of parotld neoplasms. Can J Sur9 1980;23:14-9. 3. Hughes RG, Lyons TJ. Parotld tumours, Lancet 1982;1:1080. 4. McEvedy BV, Ross WM. The treatment of mixed parotid tumours by enucleation end radiotherapy. Br J Surg 1976;63:3412, 5. McEvedy BV. Treatment of pteomorphlc adenomas by formal parotidectomy. Br J Surg 1982;69:237, 6. Stea G. Conservativesurgical treatmer~tof mixed turnouts of the parotld gland. J Maxlllofac Surg 1975;3:135-7. 7. Stevens KL, Hobsley M. The treatment of pleomorphlc adenomas by formal parotldectomy. Br J Surg 1982;69:1-3. 8. Woods JE. Parottdectomy: points of technique for brief and safe operation. Am J Surg 1983;145:678-83.
The Amedcan Journalof Surgery