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Retrograde approach for parotid benign tumours: A review
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JORMAS-215; No. of Pages 7 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Review
Retrograde approach for parotid benign tumours: A review a,b, ˜ C *, C. Chossegros a,b,c,d, P. Haen b, L. Guyot e, A. Gallucci a, N. Graillon a J. GagA a
Service de chirurgie maxillo-faciale et stomatologie, CHU Conception, 147, boulevard Baille, 13005 Marseille, France C ran, 13013 Marseille, France Service de chirurgie maxillo-faciale, stomatologie et plastique, HIA Laveran, 34, boulevard LavA˜ c Aix-Marseille university, Jardin-du-Pharo, 58, boulevard Charles-Livon, 13284 Marseille cedex 07, France d Laboratoire parole et langage (LPL), UMR 6057, 5, avenue Pasteur, 13100 Aix-en-Provence, France e Service de chirurgie maxillo-faciale, stomatologie et plastique, hoˆpital Nord, chemin des Bourrelys, 13015 Marseille, France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 June 2017 Accepted 11 August 2018
Introduction: Parotidectomy for benign tumours is usually performed after facial nerve trunk discovery through an anterograde approach (AA) of the nerve. More recently, a retrograde approach (RA) toward the facial nerve, which begins on the facial nerve branches and ends on the nerve trunk, has been described. A literature review of the RA was conducted to evaluate the RA and to compare it with AA. Methods: A literature review was conducted for the years 1980 through 2016. Nine studies out of 216 were included, including 558 parotidectomies and 370 RA. We studied the operative time (OT), the postoperative complications including facial paralysis (FP), tumour recurrences, and possibilities for reoperation. Results: Operative time was shorter in RA than in AA. Transitory FP significantly less frequent in RA than in AA in only one studies and not significantly in four studies. Incidence of Frey syndrome was similar in RA and AA. Tumour relapses were reported in 1.8% of cases with RA, comparable to AA. Conclusion: Retrograde parotidectomy is recommendable. OT was significantly shorter for the RA. The FP rate was lower for RA than for AA, but the difference was not significant. The recurrence rate appeared to be similar between RA and AA. Possibilities of reoperation were better after RA.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Retrograde Parotidectomy Facial nerve Benign tumour
1. Introduction
2. Methods
Tumours of the parotid gland account for 80% of all salivary gland neoplasms [1aˆs‘‘3]. They are benign in 80% of cases [4]. The classical treatment for parotid benign tumours remains conservative total parotidectomy with anterograde approach (AA) of the facial nerve trunk [5]. More recently conservative attitudes recommend only removing a part of the gland through a total exofacial parotidectomy (EP) or a partial EP, staying away from the tumour [6aˆs‘‘8]. A retrograde approach (RA) has more recently been described [5,8aˆs‘‘17], where the main interest is in minimising the risk of iatrogenic facial nerve (FN) injury. The aim of our study was to evaluate RA of the facial nerve for parotid benign tumour and to compare it with an anterograde approach through a literature review.
2.1. Data sources and keywords An English and French literature review was performed in the following databases: PubMed, ScienceDirect, and Google Scholar for the period covering January 1980 to April 2016 (Figs. 1 and 2). In PubMed: (Retrograde) AND (parotidectomy) in English, and ˜ C trograde) AND (Parotidectomie) in French were used. Twen(RA ty-four articles were collected in this database. In ScienceDirect: ˜ C trograde). One (retrograde parotidectomy) and (parotidectomie rA hundred forty two articles were identified. In Google Scholar: With (retrograde parotidectomy) and (parotidectomie retrograde), the first five pages of results, or the first 50 results of more than 50,000 were identified. We did not go beyond 50 because the articles did not correspond to our subject. 2.2. Criteria for inclusion and exclusion Inclusion criteria in our three databases were as follows:
* Corresponding author at: Aix-Marseille university, Jardin-du-Pharo, 58, boulevard Charles-Livon, 13284 Marseille cedex 07, France. ˜ C ). E-mail address: [email protected] (J. GagA
studies on human adults;
https://doi.org/10.1016/j.jormas.2018.08.005 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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JORMAS-215; No. of Pages 7 C et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx J. GagA˜
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Fig. 1. Study screening process.
quasi-randomised controlled trials; controlled retrospective studies; studies investigating primary benign parotid tumours; comparison of RA and AA techniques.
2.3. Evaluation criteria We evaluated operative time, postoperative complications (and, in particular, FP), recurrences, and the possibility of reoperation.
Exclusion criteria were as follows:
language other than English; abstracts only; animal studies; in vitro studies; technical notes; case report; malignant tumours; other salivary glands, including submandibular glands.
3. Results 3.1. Methodology The flowchart (Fig. 1) describes the methodology with the contents of 142 articles. Of the 142 articles collected, nine were selected; seven from PubMed, six from ScienceDirect (they also were in the PubMed selection), and two from Google Scholar.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Fig. 2. a: comparison of hypoesthesia of the ear lobe depending on the approach to the facial nerve: retrograde parotidectomy (RA); anterograde parotidectomy (AA) in partial exofacial parotidectomy (PEP); b: comparison of Frey syndrome depending on the approach to the facial nerve: retrograde parotidectomy (RA); anterograde parotidectomy (AA) in partial exofacial parotidectomy (PEP).
3.2. Included studies Nine studies were finally included, with 558 parotidectomies and 370 RA, which were performed in 554 patients. The criteria evaluated in the nine studies are shown in Table 1. Some studies only evaluated RA, while other studies compared RA with AA. The study type and duration are shown in Table 2. Of the 370 RAs, 180 were performed during a partial EP, 167 were performed during a total EP, and 23 cases were performed during total exo- and endofacial parotidectomy (TP) (Table 3). The authors studied the operative characteristics of a RA and the incidence of postoperative complications, whatever the approach to the facial nerve (Tables 4 and 5). 3.3. Epidemiology (Table 2) A female predominance was noted: 59% (ratio 1/1.7). The mean age was 50.6 years. The characteristics of the RA group and the AA
group were comparable in each of our studies. A total of 448 parotids were enrolled in six studies with a histological type of pleomorphic adenoma in 209 parotids (46.6% of tumours), and adenolymphoma in 74 parotids (16.5%). 3.4. Operative time (OT) (Tables 5 and 6) Five studies evaluated the OT with EP [9,12,13,15,16]. A total of 242 parotids were enrolled, divided into two groups. The RA group included 123 parotids; the AA group included 119 parotids. The authors compared the OT: it was 113aˆs%min in the RA group whereas it was 165aˆs%min in the AA group. The improvement in OT with RA was 50aˆs%min. For each study, the OT was significantly shorter in the RA group than in the AA group. In a retrospective study published in 2004, Bhattacharyya et al. [9] concluded that OT was 1.8aˆs%hours for the RA group
Table 1 Objectives of the studies. Author
Date
Objective
Bhattacharyya et al. OaˆsTMRegan et al. Anjum et al. Emodi et al. OaˆsTMRegan et al. Chow et al Shrestha et al Saleh et al. OaˆsTMRegan et al.
2004 2007 2008 2010 2011 2011 2011 2011 2012
Determine if P with RA is more effective than AA To evaluate the function of the facial nerve after P with AR for benign tumours Compare the incidence of postoperative complications with AR vs. AA for benign tumours Compare the surgical operations, the incidence of pre- and postoperative complications and histological data with RA vs. AA for PPA Compare the incidence of facial nerve damage (transient and permanent palsy), and its recovery with RA vs. AA for benign tumours Determine if P with RA is at least as effective, or better than AA Compare the operating time and the incidence of postoperative complications for parotidectomies with RA vs. AA for benign tumours Evaluate applicability of EP with RA, intraoperative characteristics, and the incidence of FP for PPA Evaluate the tumour recurrence rate after resection, PPA with RA
P: parotidectomy; RA: retrograde approach; AA: anterograde approach; PPA: parotid pleomorphic adenoma; EP: exofacial parotidectomy: FP: facial palsy.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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4 Table 2 Epidemiology: analysis and study methods. Authors
Publications
Country
Patients (n)
Parotids (n2)
AR (n3)
Sex
Bhattacharyya et al. OaˆsTMRegan et al. Anjum et al. Emodi et al. OaˆsTMRegan et al. Chow et al. Shrestha et al. Saleh et al. OaˆsTMRegan et al. Total
2004 2007 2008 2010 2011 2011 2011 2011 2012
USA UK UK Israel UK Hong Kong Nepal Egypt UK
45 136 84 48 40 89 48 13 51 554
45 136 89 48 40 88 48 13 51 558
26 136 40 30 20 29 25 13 51 370
W: W: W: W: W: W: W: W: W: W:
73% OR 33/45 63.2% OR 86/136 58.3% OR 49/84 60.4% OR 29/48 75% OR 30/40 36% OR 32/89 60.4% OR: 29/48 30.8% OR 4/13 68.6% OR 35/51 59% OR 327/554
Age (mean)
KOS
Duration
55.8 48 aˆs‘‘ 43.8 56 55.7 aˆs‘‘ 33.9 aˆs‘‘ 50.6
Retro Pro Retro Pro Pro Pro Retro Pro Pro aˆs‘‘
aˆs‘‘ 10 years 7 years 9 years 4 years 9.2 years 7 years 2.5 years 16 years 8.9 years
n: number of cases ; S: sex most frequently observed; W: women; KOS: kind of study; Pro: prospective; Retro: retrospective; RA: parotidectomy with retrograde approach.
Table 3 Different surgical techniques published with retrograde approach for benign parotid tumours. Authors
P
Bhattacharyya et al. (2004) OaˆsTMRegan et al. (2007) Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) OaˆsTMRegan et al. (2012) Total
45 136 89 48 40 88 48 13 51 558
RA n
Total EP
Partial EP
TP
26 136 40 30 20 29 25 13 51 370
0 114 0 0 15 0 0 0 38 167
26 11 40 30 1 29 25 13 5 180
0 11 0 0 4 0 0 0 8 23
ˆ aˆs%23.3 In 2011, Saleh [15] found an OT of 91aˆs%minaˆs%A ˆas%min in a total of 13 patients with pleomorphic adenomas. In each study, patient characteristics and tumour were comparable. They were located in the superficial lobe, or in the lower pole, or on the periphery of the gland. 3.5. Temporary or permanent FN injury (Table 4)
P: number of parotid glands operated; RA: retrograde parotidectomy; n: number of cases; EP: exofacial parotidectomy; TP: total parotidectomy.
(26 cases) whereas it was of 3.2aˆs%hours for the AA group (19 cases) (Paˆs%
A total of 370 RA were enrolled in nine studies. Whatever the FN branch, a temporary FN weakness at 1 week was noted in 48.4% of cases (179 cases). It was 39.1% at 1 month, 17.8% at 3 months, and 1.4% at 6 months. A permanent FN damage was only observed at 1 postoperative year (0.5%) [9aˆs‘‘17]. In five studies, the authors compared the temporary or permanent dysfunction of the FN in two groups, AA and RA, and all types of parotidectomy (PT or PE) [11aˆs‘‘14,16] (Table 7). In a total of 144 RA, 58 cases of transitory FN injury (40.3%) and 0 permanent FN damage were reported. In the AA group of 169 cases, 84 cases of transitional FN weakness (49.7%) and four cases of permanent FN damage (2.4%) were reported (Table 7). Just one single author concluded with a significant difference between the two groups for partial PE [12] (Paˆs%=aˆs%0.003). Thirtynine percent of patients did not report any facial deficit in the total EP with the AA group compared with ninety percent in the partial EP with RA group. In the EP with AA group, only three patients reported a permanent deficit, and in the EP with RA group, only three patients had a temporary FN weakness (compared with eight in the AA group). The four other authors concluded with a better rate for RA but the difference was not significant [11,13,14,16]. For EP only, four studies were included [11aˆs‘‘13,16]. Temporary FN weakness was reported in 31.4% of cases for RA compared with 42.9% for AA. Permanent FN damage was rare (Table 8).
Table 4 Study of postoperative facial nerve injury after parotidectomy with retrograde approach facial nerve. Authors
RA
TFNI at 1 W
TFNI at 1 M
TFNI at 3 M
TFNI at 6 M
PFNI at 1Y
Bhattacharyya et al. (2004) OaˆsTMRegan et al. (2007) Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) OaˆsTMRegan et al. (2012) Total
26 136 40 30 20 29 25 13 51 370
0 90 total: II:68; III:21; IV:1 18 3 19 total: II:7; III:11; IV:1 10 4 2 33 total: II:26; III:7 179
0 45 total: II: 44; III: 8 aˆs‘‘ aˆs‘‘ 16 total: II:11; III:5 aˆs‘‘ aˆs‘‘ aˆs‘‘ 20 total: II:18; III:2 81
0 22 total: II: 21; III: 1 aˆs‘‘ aˆs‘‘ 10 total: II:10 aˆs‘‘ aˆs‘‘ aˆs‘‘ 5 total: II:5 37
0 1 total: II:1 aˆs‘‘ aˆs‘‘ 2 total: II:2 aˆs‘‘ aˆs‘‘ aˆs‘‘ 0 3
0 1 (II) 0 0 0 0 0 0 0 1
RA: parotidectomies with retrograde approach; TFNI: temporary facial nerve injury; 1 W: 1 week; 1 M: 1 month; 3 M: 3 months; 6 M: 6 months; PFNI: permanent facial nerve injury; 1 Y: 1 year; II-III-IV-V-VI: facial palsy grade (Houseaˆs‘‘Brackmann classification).
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Table 5 Impact of operating characteristics and the main complications of parotidectomy by RA through our studies. Author
RA
OT (min)
Ear lobe numbness
Frey Sd
Tumour recurrence
Bhattacharyya et al. (2004) OaˆsTMRegan et al. (2007) Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) OaˆsTMRegan et al. (2012) Total
26 136 40 30 20 29 25 13 51 370
108 aˆs‘‘ aˆs‘‘ ˆ aˆs%42.7 145aˆs%A aˆs‘‘ ˆ aˆs%60.3) 144 (A 80 ˆ aˆs%23.3 91aˆs%A aˆs‘‘
aˆs‘‘ aˆs‘‘ aˆs‘‘ aˆs‘‘ aˆs‘‘ 11 aˆs‘‘ aˆs‘‘ aˆs‘‘ 11
aˆs‘‘ aˆs‘‘ 9 9 aˆs‘‘ 2 aˆs‘‘ 0 aˆs‘‘ 20
aˆs‘‘ aˆs‘‘ aˆs‘‘ 1 aˆs‘‘ 0 aˆs‘‘ aˆs‘‘ 1 2
RA: retrograde parotidectomy; OT: operative time (minutes).
Emodi et al. in 2009 [12] also found in his prospective study a 1/ 30 recurrence rate after EP with AR in pleomorphic adenomas.
3.6. Ear numbness (Table 5) A total of 29aˆs%EP with RA were enrolled in one study. The number of patients with postoperative ear lobe numbness was 11/ 29 cases (37.9%) [13]. The incidence of this complication is about 17% [5] to 30% [18]. Chow et al. [13] found a significant difference: 10.3% in the RA group, 59% in the AA group (Paˆs%=aˆs%0.009). 3.7. Frey syndrome (Table 5) Three studies compared the Frey syndrome occurrence in two groups, AA and RA [11aˆs‘‘13]. In a total of 99 EP with RA, 20 cases of Frey syndrome (20%) were reported. In the AA group of 126 cases, 23 cases of Frey syndrome (18.3%). Results were similar. According to Yu, RA is more common than AA in Main-land China. More than 2000 cases of RA have been performed. The incidence of FreyaˆsTMs syndrome is consistently lower in RA patients, although they are not statistically significant [23]. 3.8. Recurrences (Table 5) A total of 110 PE with RA were enrolled in three studies. Of these, 2/110 recurrences were reported [12,13,17]. The majority of studies in the literature focus on recurrence for pleomorphic adenoma of the parotid after using an AA, the recurrence rate being in this case between 2% and 20% [5,22]. O’Regan [17] compared the results with literature data for AA with pleomorphic adenomas. Fifty-one patients with pleomorphic adenoma were analysed over a 16-year period. Thirty-eight had total EP, five a partial EP, and eight a total parotidectomy. Patients were reevaluated at 1 week, 1 month, 3 months, and over 10 years later to exclude any recurrence (Table 5). The mean follow-up was 104 months; the mean tumour size was 27.4aˆs%mm. One patient developed a recurrence of a solitary nodule 8 years after the initial procedure. The recurrence rate was 2%. The limits were healthy. There was no capsular rupture. The rate was comparable to that found in the literature for AA.
4. Discussion We reported 370 parotidectomies with facial nerve RA reported in nine studies. In these articles, the patients sought treatment for an isolated tumour without facial palsy or other complication. A fine-needle aspiration cytology and magnetic resonance imaging (MRI) or computerized tomography (CT) scan were performed. The diagnosis of benign tumour was confirmed by definitive histological analysis of the surgical specimen [9aˆs‘‘17]. The characteristics of the RA group and the AA group were comparable in each of our studies. They were representative of the population. A total of 448 parotids were enrolled in six studies with a histological type of pleomorphic adenoma in 209 parotids (46.6% of tumours), and adenolymphoma in 74 parotids (16.5%). These data were consistent with the literature. The pleomorphic adenoma is the most frequent of benign tumours. It represents nearly 60% of tumours of the parotid gland [2]. Over 80% of these tumours are located in superficial lobe [19]. WhartinaˆsTMs tumour represents 5%aˆs‘‘15% of tumours of the parotid gland. It is the second most common aetiology after pleomorphic adenoma [20]. These results demonstrate that parotidectomy with RA is shorter (50aˆs%min) than with AA and reduced postoperative complications. The RA can avoid unnecessary dissection of the facial nerve trunk [13] and limit the risk of transitory and permanent FN injury. Similarly, the preservation of the great auricular nerve in RA dissection avoid the loss of ear lobe sensitivity. Current data indicates that partial EP does not compromise the surgical margins and prognosis (recurrence rate) [5,12,13,21]. But recurrence after RA is poorly studied because it is recent. No prospective study examines this criterion. Furthermore, surgical revision is also easier in circumstances where the trunk has not been previously dissected [10,14,17].
Table 6 Operative time of PE according to approach to the first facial nerve: AA and RA (minutes). Author
Bhattacharyya et al. (2004) Emodi et al. (2010) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) Total
RA
AA
P
n
Duration
n
Duration
26 30 29 25 13 123
108 145 144 80 91 Mean: 113
19 18 59 23 aˆs‘‘ 119
192 171 176.2 110 aˆs‘‘ Mean: 165
RA: parotidectomies with retrograde approach; AA: parotidectomies with anterograde approach; n: number of cases; P: significance index.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Table 7 Comparison of temporary and permanent facial nerve (FN) injury depending on the approach to the FN: retrograde parotidectomy (RA); anterograde parotidectomy (AA); any kind of resection. Authors
Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Total
P
RA
89 48 40 88 48 313
AA
n
Temporary FN injury
Permanent FN injury
n
Temporary FN injury
Permanent FN injury
40 30 20 29 25 144
22 3 19 10 4 58 (40.3%)
0 0 0 0 0 0
49 18 20 59 23 169
22 8 20 31 3 84 (49.7%)
0 3 0 1 0 4 (2.4%)
P: parotidectomies; RA: parotidectomies with retrograde approach; AA: parotidectomies with anterograde approach; n: number of cases.
Table 8 Comparison of temporary and permanent facial nerve (FN) injury depending on the approach to the facial nerve: retrograde parotidectomy (RA); anterograde parotidectomy (AA) in partial exofacial parotidectomy (PEP). Authors
Anjum et al. (2008) Emodi et al. (2010) Chow et al. (2011) Shrestha et al. (2011) Total
PEP
89 48 88 48 225
RA
AA
n
Temporary FN injury
Permanent FN injury
n
Temporary FN injury
Permanent FN injury
40 30 29 25 94
22 3 10 4 39 (31.4%)
0 0 0 0 0
49 18 59 23 149
22 8 31 3 64 (42.9%)
0 3 1 0 4 (2.7%)
PEP: partial exofacial parotidectomy; RA: parotidectomies with retrograde approach; AA: parotidectomies with anterograde approach; n: number of cases; FN: facial nerve.
Some studies have been retrospectively conducted [9,11,16]. The possibility of a selection bias exists. Smaller lesions may have been unconsciously performed with RA. Consequently, it would seem prudent to recommend that the RA should always been considered for simple cases, which are benign with a favourable location. Recommendations about the surgical treatment of benign parotid gland tumours are changing. Partial parotidectomies and extended tumorectomy are most frequently indicated, even for pleomorphic adenomas [6aˆs‘‘8]. For benign tumours, complete dissection of FN and its trunk can be prevented by RA. 5. Conclusion Our study demonstrate that RA of the FN diminishes significantly the duration of parotidectomies and therefore the percentage of intraoperative complications. With RA, FN injury, Frey syndrome, or hypoesthesia of the earlobe are lower than with AA. The recurrence is not more frequent, so the oncologic efficacy is at least as satisfactory as the conventional technique for benign tumours. RA, described for the first time in the 1920aˆs%s [24,25] and ignored in favor of AA, seems to have an interest for some indications: benign and small tumours, situated in the superficial lobe, in the lower pole, or localised in the periphery of the gland [13,23]. RA is also of interest for obese individuals where the nerve trunk can be deep [26]. RA is a simple and reproducible technique that therefore deserves to have a place in the therapeutic arsenal of parotid benign tumours. Disclosure of interest The authors declare having no competing interest.
Acknowledgment This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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[17] OaˆsTMRegan B, Bharadwaj G. Tumour recurrence after surgical removal of parotid pleomorphic salivary adenoma using a retrograde facial nerve dissection technique. Br J Oral Maxillofac Surg 2012;50:417–9. [18] Marshall AH, Quraishi SM, Bradley PJ. PatientsaˆsTM perspectives on the short and long term outcomes following surgery for benign parotid neoplasms. J Laryngol Otol 2003;117:624–9. [19] Achour I, Chakroun A, Ben Rhaiem Z, Charfeddine I, Hammami B, et al. Surgery of pleomorphic adenoma of the parotid gland. Rev Stomatol Chir Maxillofac 2015;116:129–31. [20] Paris J, Facon F, Chrestian MA, Giovanni A, Zanaret M. Diagnostic et traitement ˜ C sentation clinique, ponction cytologique des tumeurs de Whartinaˆs%: prA et IRM. Rev Laryngol Otol Rhinol 2004;125:65–9. [21] OaˆsTMBrien CJ. Current management of benign parotid tumorsaˆs%aˆs‘‘aˆs%The role of limited superficial parotidectomy. Head Neck 2003;25:946–52.
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[22] Ghosh S, Panarese A, Bull PD, Lee JA. Marginally excised parotid pleomorphic salivary adenomas: risk factors for recurrence and management. A 12.5-year mean follow-up study of histologically marginal excisions. Clin Otolaryngol Allied Sci 2003;28:262–6. [23] Yu G-Y. Superficial parotidectomy through retrograde facial nerve dissection. JR Coll Surg Edinb 2001;46:104–7. [24] Sistrunk WE. Tumor of the parotid gland. S Clin N Am 1921;1:1515–21. [25] Adson AW, Ott WO. Preservation of facial nerve in radical treatment of parotid tumors. Arch Surg 1923;6:739–46. [26] Adeyemo WL, Taiwo OA, Somefun OA, Olasoji HO, Ndukwe KC, et al. A survey of facial nerve dissection techniques in benign parotid surgery among maxillofacial and ear, nose and throat surgeons in Nigeria. Nig J Clin Pract 2011;14:83–7.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
JORMAS-215; No. of Pages 7 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Review
Retrograde approach for parotid benign tumours: A review a,b, ˜ C *, C. Chossegros a,b,c,d, P. Haen b, L. Guyot e, A. Gallucci a, N. Graillon a J. GagA a
Service de chirurgie maxillo-faciale et stomatologie, CHU Conception, 147, boulevard Baille, 13005 Marseille, France C ran, 13013 Marseille, France Service de chirurgie maxillo-faciale, stomatologie et plastique, HIA Laveran, 34, boulevard LavA˜ c Aix-Marseille university, Jardin-du-Pharo, 58, boulevard Charles-Livon, 13284 Marseille cedex 07, France d Laboratoire parole et langage (LPL), UMR 6057, 5, avenue Pasteur, 13100 Aix-en-Provence, France e Service de chirurgie maxillo-faciale, stomatologie et plastique, hoˆpital Nord, chemin des Bourrelys, 13015 Marseille, France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 June 2017 Accepted 11 August 2018
Introduction: Parotidectomy for benign tumours is usually performed after facial nerve trunk discovery through an anterograde approach (AA) of the nerve. More recently, a retrograde approach (RA) toward the facial nerve, which begins on the facial nerve branches and ends on the nerve trunk, has been described. A literature review of the RA was conducted to evaluate the RA and to compare it with AA. Methods: A literature review was conducted for the years 1980 through 2016. Nine studies out of 216 were included, including 558 parotidectomies and 370 RA. We studied the operative time (OT), the postoperative complications including facial paralysis (FP), tumour recurrences, and possibilities for reoperation. Results: Operative time was shorter in RA than in AA. Transitory FP significantly less frequent in RA than in AA in only one studies and not significantly in four studies. Incidence of Frey syndrome was similar in RA and AA. Tumour relapses were reported in 1.8% of cases with RA, comparable to AA. Conclusion: Retrograde parotidectomy is recommendable. OT was significantly shorter for the RA. The FP rate was lower for RA than for AA, but the difference was not significant. The recurrence rate appeared to be similar between RA and AA. Possibilities of reoperation were better after RA.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Retrograde Parotidectomy Facial nerve Benign tumour
1. Introduction
2. Methods
Tumours of the parotid gland account for 80% of all salivary gland neoplasms [1aˆs‘‘3]. They are benign in 80% of cases [4]. The classical treatment for parotid benign tumours remains conservative total parotidectomy with anterograde approach (AA) of the facial nerve trunk [5]. More recently conservative attitudes recommend only removing a part of the gland through a total exofacial parotidectomy (EP) or a partial EP, staying away from the tumour [6aˆs‘‘8]. A retrograde approach (RA) has more recently been described [5,8aˆs‘‘17], where the main interest is in minimising the risk of iatrogenic facial nerve (FN) injury. The aim of our study was to evaluate RA of the facial nerve for parotid benign tumour and to compare it with an anterograde approach through a literature review.
2.1. Data sources and keywords An English and French literature review was performed in the following databases: PubMed, ScienceDirect, and Google Scholar for the period covering January 1980 to April 2016 (Figs. 1 and 2). In PubMed: (Retrograde) AND (parotidectomy) in English, and ˜ C trograde) AND (Parotidectomie) in French were used. Twen(RA ty-four articles were collected in this database. In ScienceDirect: ˜ C trograde). One (retrograde parotidectomy) and (parotidectomie rA hundred forty two articles were identified. In Google Scholar: With (retrograde parotidectomy) and (parotidectomie retrograde), the first five pages of results, or the first 50 results of more than 50,000 were identified. We did not go beyond 50 because the articles did not correspond to our subject. 2.2. Criteria for inclusion and exclusion Inclusion criteria in our three databases were as follows:
* Corresponding author at: Aix-Marseille university, Jardin-du-Pharo, 58, boulevard Charles-Livon, 13284 Marseille cedex 07, France. ˜ C ). E-mail address: [email protected] (J. GagA
studies on human adults;
https://doi.org/10.1016/j.jormas.2018.08.005 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Fig. 1. Study screening process.
quasi-randomised controlled trials; controlled retrospective studies; studies investigating primary benign parotid tumours; comparison of RA and AA techniques.
2.3. Evaluation criteria We evaluated operative time, postoperative complications (and, in particular, FP), recurrences, and the possibility of reoperation.
Exclusion criteria were as follows:
language other than English; abstracts only; animal studies; in vitro studies; technical notes; case report; malignant tumours; other salivary glands, including submandibular glands.
3. Results 3.1. Methodology The flowchart (Fig. 1) describes the methodology with the contents of 142 articles. Of the 142 articles collected, nine were selected; seven from PubMed, six from ScienceDirect (they also were in the PubMed selection), and two from Google Scholar.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Fig. 2. a: comparison of hypoesthesia of the ear lobe depending on the approach to the facial nerve: retrograde parotidectomy (RA); anterograde parotidectomy (AA) in partial exofacial parotidectomy (PEP); b: comparison of Frey syndrome depending on the approach to the facial nerve: retrograde parotidectomy (RA); anterograde parotidectomy (AA) in partial exofacial parotidectomy (PEP).
3.2. Included studies Nine studies were finally included, with 558 parotidectomies and 370 RA, which were performed in 554 patients. The criteria evaluated in the nine studies are shown in Table 1. Some studies only evaluated RA, while other studies compared RA with AA. The study type and duration are shown in Table 2. Of the 370 RAs, 180 were performed during a partial EP, 167 were performed during a total EP, and 23 cases were performed during total exo- and endofacial parotidectomy (TP) (Table 3). The authors studied the operative characteristics of a RA and the incidence of postoperative complications, whatever the approach to the facial nerve (Tables 4 and 5). 3.3. Epidemiology (Table 2) A female predominance was noted: 59% (ratio 1/1.7). The mean age was 50.6 years. The characteristics of the RA group and the AA
group were comparable in each of our studies. A total of 448 parotids were enrolled in six studies with a histological type of pleomorphic adenoma in 209 parotids (46.6% of tumours), and adenolymphoma in 74 parotids (16.5%). 3.4. Operative time (OT) (Tables 5 and 6) Five studies evaluated the OT with EP [9,12,13,15,16]. A total of 242 parotids were enrolled, divided into two groups. The RA group included 123 parotids; the AA group included 119 parotids. The authors compared the OT: it was 113aˆs%min in the RA group whereas it was 165aˆs%min in the AA group. The improvement in OT with RA was 50aˆs%min. For each study, the OT was significantly shorter in the RA group than in the AA group. In a retrospective study published in 2004, Bhattacharyya et al. [9] concluded that OT was 1.8aˆs%hours for the RA group
Table 1 Objectives of the studies. Author
Date
Objective
Bhattacharyya et al. OaˆsTMRegan et al. Anjum et al. Emodi et al. OaˆsTMRegan et al. Chow et al Shrestha et al Saleh et al. OaˆsTMRegan et al.
2004 2007 2008 2010 2011 2011 2011 2011 2012
Determine if P with RA is more effective than AA To evaluate the function of the facial nerve after P with AR for benign tumours Compare the incidence of postoperative complications with AR vs. AA for benign tumours Compare the surgical operations, the incidence of pre- and postoperative complications and histological data with RA vs. AA for PPA Compare the incidence of facial nerve damage (transient and permanent palsy), and its recovery with RA vs. AA for benign tumours Determine if P with RA is at least as effective, or better than AA Compare the operating time and the incidence of postoperative complications for parotidectomies with RA vs. AA for benign tumours Evaluate applicability of EP with RA, intraoperative characteristics, and the incidence of FP for PPA Evaluate the tumour recurrence rate after resection, PPA with RA
P: parotidectomy; RA: retrograde approach; AA: anterograde approach; PPA: parotid pleomorphic adenoma; EP: exofacial parotidectomy: FP: facial palsy.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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4 Table 2 Epidemiology: analysis and study methods. Authors
Publications
Country
Patients (n)
Parotids (n2)
AR (n3)
Sex
Bhattacharyya et al. OaˆsTMRegan et al. Anjum et al. Emodi et al. OaˆsTMRegan et al. Chow et al. Shrestha et al. Saleh et al. OaˆsTMRegan et al. Total
2004 2007 2008 2010 2011 2011 2011 2011 2012
USA UK UK Israel UK Hong Kong Nepal Egypt UK
45 136 84 48 40 89 48 13 51 554
45 136 89 48 40 88 48 13 51 558
26 136 40 30 20 29 25 13 51 370
W: W: W: W: W: W: W: W: W: W:
73% OR 33/45 63.2% OR 86/136 58.3% OR 49/84 60.4% OR 29/48 75% OR 30/40 36% OR 32/89 60.4% OR: 29/48 30.8% OR 4/13 68.6% OR 35/51 59% OR 327/554
Age (mean)
KOS
Duration
55.8 48 aˆs‘‘ 43.8 56 55.7 aˆs‘‘ 33.9 aˆs‘‘ 50.6
Retro Pro Retro Pro Pro Pro Retro Pro Pro aˆs‘‘
aˆs‘‘ 10 years 7 years 9 years 4 years 9.2 years 7 years 2.5 years 16 years 8.9 years
n: number of cases ; S: sex most frequently observed; W: women; KOS: kind of study; Pro: prospective; Retro: retrospective; RA: parotidectomy with retrograde approach.
Table 3 Different surgical techniques published with retrograde approach for benign parotid tumours. Authors
P
Bhattacharyya et al. (2004) OaˆsTMRegan et al. (2007) Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) OaˆsTMRegan et al. (2012) Total
45 136 89 48 40 88 48 13 51 558
RA n
Total EP
Partial EP
TP
26 136 40 30 20 29 25 13 51 370
0 114 0 0 15 0 0 0 38 167
26 11 40 30 1 29 25 13 5 180
0 11 0 0 4 0 0 0 8 23
ˆ aˆs%23.3 In 2011, Saleh [15] found an OT of 91aˆs%minaˆs%A ˆas%min in a total of 13 patients with pleomorphic adenomas. In each study, patient characteristics and tumour were comparable. They were located in the superficial lobe, or in the lower pole, or on the periphery of the gland. 3.5. Temporary or permanent FN injury (Table 4)
P: number of parotid glands operated; RA: retrograde parotidectomy; n: number of cases; EP: exofacial parotidectomy; TP: total parotidectomy.
(26 cases) whereas it was of 3.2aˆs%hours for the AA group (19 cases) (Paˆs%
A total of 370 RA were enrolled in nine studies. Whatever the FN branch, a temporary FN weakness at 1 week was noted in 48.4% of cases (179 cases). It was 39.1% at 1 month, 17.8% at 3 months, and 1.4% at 6 months. A permanent FN damage was only observed at 1 postoperative year (0.5%) [9aˆs‘‘17]. In five studies, the authors compared the temporary or permanent dysfunction of the FN in two groups, AA and RA, and all types of parotidectomy (PT or PE) [11aˆs‘‘14,16] (Table 7). In a total of 144 RA, 58 cases of transitory FN injury (40.3%) and 0 permanent FN damage were reported. In the AA group of 169 cases, 84 cases of transitional FN weakness (49.7%) and four cases of permanent FN damage (2.4%) were reported (Table 7). Just one single author concluded with a significant difference between the two groups for partial PE [12] (Paˆs%=aˆs%0.003). Thirtynine percent of patients did not report any facial deficit in the total EP with the AA group compared with ninety percent in the partial EP with RA group. In the EP with AA group, only three patients reported a permanent deficit, and in the EP with RA group, only three patients had a temporary FN weakness (compared with eight in the AA group). The four other authors concluded with a better rate for RA but the difference was not significant [11,13,14,16]. For EP only, four studies were included [11aˆs‘‘13,16]. Temporary FN weakness was reported in 31.4% of cases for RA compared with 42.9% for AA. Permanent FN damage was rare (Table 8).
Table 4 Study of postoperative facial nerve injury after parotidectomy with retrograde approach facial nerve. Authors
RA
TFNI at 1 W
TFNI at 1 M
TFNI at 3 M
TFNI at 6 M
PFNI at 1Y
Bhattacharyya et al. (2004) OaˆsTMRegan et al. (2007) Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) OaˆsTMRegan et al. (2012) Total
26 136 40 30 20 29 25 13 51 370
0 90 total: II:68; III:21; IV:1 18 3 19 total: II:7; III:11; IV:1 10 4 2 33 total: II:26; III:7 179
0 45 total: II: 44; III: 8 aˆs‘‘ aˆs‘‘ 16 total: II:11; III:5 aˆs‘‘ aˆs‘‘ aˆs‘‘ 20 total: II:18; III:2 81
0 22 total: II: 21; III: 1 aˆs‘‘ aˆs‘‘ 10 total: II:10 aˆs‘‘ aˆs‘‘ aˆs‘‘ 5 total: II:5 37
0 1 total: II:1 aˆs‘‘ aˆs‘‘ 2 total: II:2 aˆs‘‘ aˆs‘‘ aˆs‘‘ 0 3
0 1 (II) 0 0 0 0 0 0 0 1
RA: parotidectomies with retrograde approach; TFNI: temporary facial nerve injury; 1 W: 1 week; 1 M: 1 month; 3 M: 3 months; 6 M: 6 months; PFNI: permanent facial nerve injury; 1 Y: 1 year; II-III-IV-V-VI: facial palsy grade (Houseaˆs‘‘Brackmann classification).
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Table 5 Impact of operating characteristics and the main complications of parotidectomy by RA through our studies. Author
RA
OT (min)
Ear lobe numbness
Frey Sd
Tumour recurrence
Bhattacharyya et al. (2004) OaˆsTMRegan et al. (2007) Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) OaˆsTMRegan et al. (2012) Total
26 136 40 30 20 29 25 13 51 370
108 aˆs‘‘ aˆs‘‘ ˆ aˆs%42.7 145aˆs%A aˆs‘‘ ˆ aˆs%60.3) 144 (A 80 ˆ aˆs%23.3 91aˆs%A aˆs‘‘
aˆs‘‘ aˆs‘‘ aˆs‘‘ aˆs‘‘ aˆs‘‘ 11 aˆs‘‘ aˆs‘‘ aˆs‘‘ 11
aˆs‘‘ aˆs‘‘ 9 9 aˆs‘‘ 2 aˆs‘‘ 0 aˆs‘‘ 20
aˆs‘‘ aˆs‘‘ aˆs‘‘ 1 aˆs‘‘ 0 aˆs‘‘ aˆs‘‘ 1 2
RA: retrograde parotidectomy; OT: operative time (minutes).
Emodi et al. in 2009 [12] also found in his prospective study a 1/ 30 recurrence rate after EP with AR in pleomorphic adenomas.
3.6. Ear numbness (Table 5) A total of 29aˆs%EP with RA were enrolled in one study. The number of patients with postoperative ear lobe numbness was 11/ 29 cases (37.9%) [13]. The incidence of this complication is about 17% [5] to 30% [18]. Chow et al. [13] found a significant difference: 10.3% in the RA group, 59% in the AA group (Paˆs%=aˆs%0.009). 3.7. Frey syndrome (Table 5) Three studies compared the Frey syndrome occurrence in two groups, AA and RA [11aˆs‘‘13]. In a total of 99 EP with RA, 20 cases of Frey syndrome (20%) were reported. In the AA group of 126 cases, 23 cases of Frey syndrome (18.3%). Results were similar. According to Yu, RA is more common than AA in Main-land China. More than 2000 cases of RA have been performed. The incidence of FreyaˆsTMs syndrome is consistently lower in RA patients, although they are not statistically significant [23]. 3.8. Recurrences (Table 5) A total of 110 PE with RA were enrolled in three studies. Of these, 2/110 recurrences were reported [12,13,17]. The majority of studies in the literature focus on recurrence for pleomorphic adenoma of the parotid after using an AA, the recurrence rate being in this case between 2% and 20% [5,22]. O’Regan [17] compared the results with literature data for AA with pleomorphic adenomas. Fifty-one patients with pleomorphic adenoma were analysed over a 16-year period. Thirty-eight had total EP, five a partial EP, and eight a total parotidectomy. Patients were reevaluated at 1 week, 1 month, 3 months, and over 10 years later to exclude any recurrence (Table 5). The mean follow-up was 104 months; the mean tumour size was 27.4aˆs%mm. One patient developed a recurrence of a solitary nodule 8 years after the initial procedure. The recurrence rate was 2%. The limits were healthy. There was no capsular rupture. The rate was comparable to that found in the literature for AA.
4. Discussion We reported 370 parotidectomies with facial nerve RA reported in nine studies. In these articles, the patients sought treatment for an isolated tumour without facial palsy or other complication. A fine-needle aspiration cytology and magnetic resonance imaging (MRI) or computerized tomography (CT) scan were performed. The diagnosis of benign tumour was confirmed by definitive histological analysis of the surgical specimen [9aˆs‘‘17]. The characteristics of the RA group and the AA group were comparable in each of our studies. They were representative of the population. A total of 448 parotids were enrolled in six studies with a histological type of pleomorphic adenoma in 209 parotids (46.6% of tumours), and adenolymphoma in 74 parotids (16.5%). These data were consistent with the literature. The pleomorphic adenoma is the most frequent of benign tumours. It represents nearly 60% of tumours of the parotid gland [2]. Over 80% of these tumours are located in superficial lobe [19]. WhartinaˆsTMs tumour represents 5%aˆs‘‘15% of tumours of the parotid gland. It is the second most common aetiology after pleomorphic adenoma [20]. These results demonstrate that parotidectomy with RA is shorter (50aˆs%min) than with AA and reduced postoperative complications. The RA can avoid unnecessary dissection of the facial nerve trunk [13] and limit the risk of transitory and permanent FN injury. Similarly, the preservation of the great auricular nerve in RA dissection avoid the loss of ear lobe sensitivity. Current data indicates that partial EP does not compromise the surgical margins and prognosis (recurrence rate) [5,12,13,21]. But recurrence after RA is poorly studied because it is recent. No prospective study examines this criterion. Furthermore, surgical revision is also easier in circumstances where the trunk has not been previously dissected [10,14,17].
Table 6 Operative time of PE according to approach to the first facial nerve: AA and RA (minutes). Author
Bhattacharyya et al. (2004) Emodi et al. (2010) Chow et al. (2011) Shrestha et al. (2011) Saleh et al. (2011) Total
RA
AA
P
n
Duration
n
Duration
26 30 29 25 13 123
108 145 144 80 91 Mean: 113
19 18 59 23 aˆs‘‘ 119
192 171 176.2 110 aˆs‘‘ Mean: 165
RA: parotidectomies with retrograde approach; AA: parotidectomies with anterograde approach; n: number of cases; P: significance index.
˜ C J, et al. Retrograde approach for parotid benign tumours: A review. J Stomatol Oral Maxillofac Please cite this article in press as: GagA Surg (2018), https://doi.org/10.1016/j.jormas.2018.08.005
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Table 7 Comparison of temporary and permanent facial nerve (FN) injury depending on the approach to the FN: retrograde parotidectomy (RA); anterograde parotidectomy (AA); any kind of resection. Authors
Anjum et al. (2008) Emodi et al. (2010) OaˆsTMRegan et al. (2011) Chow et al. (2011) Shrestha et al. (2011) Total
P
RA
89 48 40 88 48 313
AA
n
Temporary FN injury
Permanent FN injury
n
Temporary FN injury
Permanent FN injury
40 30 20 29 25 144
22 3 19 10 4 58 (40.3%)
0 0 0 0 0 0
49 18 20 59 23 169
22 8 20 31 3 84 (49.7%)
0 3 0 1 0 4 (2.4%)
P: parotidectomies; RA: parotidectomies with retrograde approach; AA: parotidectomies with anterograde approach; n: number of cases.
Table 8 Comparison of temporary and permanent facial nerve (FN) injury depending on the approach to the facial nerve: retrograde parotidectomy (RA); anterograde parotidectomy (AA) in partial exofacial parotidectomy (PEP). Authors
Anjum et al. (2008) Emodi et al. (2010) Chow et al. (2011) Shrestha et al. (2011) Total
PEP
89 48 88 48 225
RA
AA
n
Temporary FN injury
Permanent FN injury
n
Temporary FN injury
Permanent FN injury
40 30 29 25 94
22 3 10 4 39 (31.4%)
0 0 0 0 0
49 18 59 23 149
22 8 31 3 64 (42.9%)
0 3 1 0 4 (2.7%)
PEP: partial exofacial parotidectomy; RA: parotidectomies with retrograde approach; AA: parotidectomies with anterograde approach; n: number of cases; FN: facial nerve.
Some studies have been retrospectively conducted [9,11,16]. The possibility of a selection bias exists. Smaller lesions may have been unconsciously performed with RA. Consequently, it would seem prudent to recommend that the RA should always been considered for simple cases, which are benign with a favourable location. Recommendations about the surgical treatment of benign parotid gland tumours are changing. Partial parotidectomies and extended tumorectomy are most frequently indicated, even for pleomorphic adenomas [6aˆs‘‘8]. For benign tumours, complete dissection of FN and its trunk can be prevented by RA. 5. Conclusion Our study demonstrate that RA of the FN diminishes significantly the duration of parotidectomies and therefore the percentage of intraoperative complications. With RA, FN injury, Frey syndrome, or hypoesthesia of the earlobe are lower than with AA. The recurrence is not more frequent, so the oncologic efficacy is at least as satisfactory as the conventional technique for benign tumours. RA, described for the first time in the 1920aˆs%s [24,25] and ignored in favor of AA, seems to have an interest for some indications: benign and small tumours, situated in the superficial lobe, in the lower pole, or localised in the periphery of the gland [13,23]. RA is also of interest for obese individuals where the nerve trunk can be deep [26]. RA is a simple and reproducible technique that therefore deserves to have a place in the therapeutic arsenal of parotid benign tumours. Disclosure of interest The authors declare having no competing interest.
Acknowledgment This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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