Total parotidectomy for mixed tumor

Total

Parotidectomy KOBEKT IV. UTENDOKFER,

From /be Department of Surgery of tlJe Veteruns trution Hospital, Minneapolis, Minnesota.

for Mixed M.D., AL~inneccpolis,

Adminis-

,lli,znesotu

Because of this real threat of recurrence, the increased risk of facial nerve injury with subsequent operations in a scarred area and the

tumors of the parotid are the most common neoplasms of salivary gland they are not malignant by origin. Although usual criteria,’ neither are they strictly benign. It is possible that they represent, as suggested by WiIIis,2 a stage in progression between a benign and a definitely malignant lesion. That these tumors are likely to recur is well recorded, such recurrence depending on the type of treatment and Iength of time the patlents are followed up. Statistics on recurrence vary but a conservatix-e estimate of the average rate is about 25 per cent.” A number of factors contribute to this high figure: (I) One cause is incomplete removal due to reluctance on the part of the surgeon to carr!out a wide escision in an area traversed by the facial nerve. Lack of understanding of the anatomy of the area and unfamiliarity with the problem result in timid excision, too fre. yuentIy. done with local anesthesia under the impressIon that these tumors are always benign. (Fig. I.) (2) There can be error in diagnosis. I have seen a number of patients with recurrent tumors who were first operated upon under IocaI anesthesia for “biopsy of a Iymph node” or “removal of a cyst,” resulting in an incomplete removal of a parotid tumor after a tedious and distressing episode for both patient and physician. (3) The presence of satellite nodules, a characteristic of these muIticentric tumors, is another factor producing recurrence \vhen the tumors are removed by the usual extracapsular dissection which ma) aIIow daughter noduIes to remain. This has been mentioned by XIcFarIand,3a4 who found that smalI tumors tended to recur more frequently than large tumors. He speculated that surgery may best be deIayed to allow coalescence of these noduIes, i.e., that the tumor be aIIowed to “ripen” before excision. (4) Careful microscopic study of mixed tumors 41 show penetration of the capsule by tumor cells (28 per cent in some series) B -another invitation to recurrence.

M

Tumor

IXED

FIG. I. Recurrent mixed tumor two years after incomplete removal through inadequate, poorly placed incision.

possibility of malignant change” or primary low grade maIignancy, it is evident that the fate of the patient with a mixed tumor depends on the surgeon who operates upon him for the first time. Therefore, the first operation must be thorough, to reduce recurrence, and at the same time should avoid injury to the facial nerve. Diagnosis. The diagnosis of parotid tumor is usuaIIy not difhcult although a firm cyst deep in the gland may accurately simuIate neoplasm. I have been impressed by the frequency of lesions occurring in the isthmus of the gland (nine of twenty in the series reported herein) where they may he mistaken for enlarged lymph nodes. 159

American

.Jou~nul

oj Surgery.

Volume

yr,

February,

1956

Utendorfer The differentia1 diagnosis between carcinoma and benign tumor is possible cIinicaIly in most Important features are Iisted in instances. Table I. Of particular significance is the presence of pain, facial paralysis or metastases. Some malignancies tend to be Aat, inf3trative TABLE

Features

I

Benign or Mixed Tumor

Malignant

..I_

Duration. .............. Age (yr.) ............... Size (variabIe) ..........

Long

Short

4oSlow growth

Contour.

Projects

4of Rapid or increasing May be Aat, inhItrative Hard More Iixed Frequent Frequent Frequent

..............

Consistency. ........... Mobilitv. .............. Pain. .Y............... ParaIysis. .............. Metastases. ............

Firm-hard Slight Not usua1 UnusuaI None

and less conspicuous, and do not dispIace the Iobe of ear as do the benign tumors. I have not taken preIiminary biopsy specimens because of danger of impIanting tumor ceIIs, but I have exposed the tumor at operation and have taken biopsy specimens onIy of those suspected of being maIignant. The dificuIties in interpreting frozen sections of these tumors make this of vaIue only in unequivocal carcinomas. I have not found siaIography to be of vaIue in differentiating tumors, but it wiII demonstrate obstruction to the ducts. CIinicaI error occurred in three “mixed tumors” situated deep in the pIand. On removal by total parotidectomy they were found to be denseIy encapsuIated cysts. It may be that a biopsy specimen shouId be taken at operation in each case to prevent this occurrence, but mixed tumors may undergo secondary necrosis. Anatomic Considerations. ProbabIy the first accurate description of the surgicat anatomy of the parotid was given by Bailey? who confirmed the earlier findings of McWhorter,* demonstrating that the faciaI nerve does not pass through the gIand in a strict sense but is situated between the superficia1 and deep Iobes, enclosed in the parotidomakseteric fascia. BaiIey advocated removal of the entire gland with preservation of the nervi, and he presented

a scheme for mobilizing the superficial lobe. Further detaited description of the faciaI nerve has been given by McCormack et aI.9 Technic. Since 1946 I have empIoyed tota parotidectomy in the treatment of mixed tumors and during this period have performed the procedure twenty-three times, an additional patient having been treated by superficial Iobectomy. The operation is performed under genera1 intratrachea1 anesthesia the patient being draped with the ear exposed for orientation. A “J” or “Y” incisionLoll is made and the superficia1 Iobe of the gland exposed. Dissection is then begun along the anterior margin of the superficia1 lobe, identifying the branches of the facia1 nerve and tracing them in a centripeta direction. To faciIitate this the parotid duct is identified, divided and the proxima1 end is grasped with a forcep and, using this as an instrument of traction, the superficia1 Iobe is gentIy eIevated. Once the two major divisions of the nerve are identified (as they fork about the isthmus) the dissection of the isthmus and deep lobe is not difficult, provided it is not hurried and is done carefuIIy. The normal reIationship of the nerve may be distorted by tumor and the operator must be aIert to this. The periphera1 portions of the nerve are not usuaIIy thus dispIaced. I have not found it necessary to ligate the externa1 carotid, but the carefu1 maintenance of hemostasis is essential. In one patient the main trunk of the facia1 nerve was identified first and dissection carried peripheraIIy from this point, but the approach seemed more difficult. In onIy one patient with a superficia1 tumor was superficia1 Iobectomy done, preserving the deep Iobe. SuperficiaI Iobectomy does not appear to be a wise procedure since the dif&uIt part of the dissection is compteted when the superficia1 Iobe is mobiIized and the nerve exposed. MATERIAL A summary sented

in Table

of the II.

patients

treated

is pre-

It wiII be noted that of the twenty patients with primary mixed tumors, simpIe excision was performed in two. One patient was so seIected because of age (sixtyone) and three previous cerebrovascutar accidents. LocaI anesthesia was used but is not recommended for the usua1 case. In the other patient the tumor was peduncutated and attached to the parotid by a thin staIk. TotaI

160

TotaI

Parotidectomy

for Mixed

Tumor

TABLE II

T

Location

Deep or in Isthmus

Injury

to Nerve

~~~~~‘;

Temporary Weakness

TotaI ’ Gustatory ’ Parotid_ [ Superficial , Sweating 1 CCtOmVi Lobectomy

Excision

Mandibular Division

Primary mixed tumor.. Recurrent mixed tumor.. Adenolymphoma Cyst.

20

II

9

7

2

‘7

I

2

2

2

3

i this is too short a period to be significant since McFarland has recorded recurrences (new tumors?) forty-five years after removal,3 but most recurrences will appear within four years and the majority of these occur in the first year.6 However, if one is permitted to compare these with mixed tumors of the submaxillary which rarely recur after total submaxillary excision,12.13 a prediction can be made that total parotidectomy may produce similar results. Also, daughter tumors and extracapsular penetrations will be removed by total parotidectomy, whereas they may be allowed to remain when extracapsular dissection is done. (Figs. 2 and 3.) The difficulty of excising the tumor and a rim of normal parotid to encompass these nodules is obvious. Facial Nerre Injury. Permanent complete facial nerve paralysis has not occurred, but two patients have slight non-disfiguring weakness of a portion of the mandibuIar division; one of these patients was operated upon for recurrent tumor. Eight additional patients have had temporary weakness of one or more of the divisions of the nerve (usually mandibular). This usually appears on the day following surgery, suggesting edema and functional interruption of the nerve, and has cleared completely in several weeks except for the two patients with persistent weakness. Treatment of this condition has been support to the angIe of the mouth by tape or an acrylic loop and galvanic stimulation to preserve muscle tone pending recovery of function. Three patients have had sweating of the cheek on the operated side associated with meals (“gustatory sweating,” Frey syndrome).

parotidectomy had been contemplated, but the findings at operation suggested that simple excision including the parotid attachment might be sufficient. One patient with an adenolymphoma was subjected to total parotidectomy. ClinicalIy this was thought to be a mixed tumor and a biopsy specimen was not taken at operation. Adenolymphomas are uncommon tumors, probably are entirely benign, but may recur if incompletely removed. It is IikeIy that extracapsular excision of this tumor would have been adequate treatment and that taking a biopsy specimen at operation would have reveaIed its Differentiation of an adenotrue nature. lymphoma from a mixed tumor is not possible on clinical grounds; to date there is no record of one being diagnosed preoperatively. As indicated previously, total parotidectomy was performed on three patients for cysts within the gland. In each instance the cyst was densely encapsulated and was thought to be a mixed tumor. Histologic examination, however, failed to reveal tumor in the wall of the removed specimens and the etiology of these is obscure, there being no evidence of duct obstruction. Again, taking a biopsy specimen at operation may have identified these lesions as cysts, but an occasional mixed tumor may undergo cystic degeneration or inflammatory change to cause further confusion. RESGLTS

Recurrences. There have been no recurrences in this series--the average length of follow-up is thirty-three months with extremes of one month and eighty months. Admittedly,

161

Utendorfer

FIG. 2. Typical daughter tumor (C) separated from main tumor (A) by capsuIe (B). Extracapsutar removal of tumor may ahow sateI!ite nodule to reX 15.) main. (OriginaI magnification, FIG. 3. Penetration x 100.)

of capsule

(B) by tumor celIs (C). (Original magnification,

2. ProIonged follow-up is necessary to evaluate statistically this procedure, but it shouId yield improved results for stated reasons. 3. The procedure is technicaIIy feasibIe but shouId not be undertaken without fuI1 understanding of the anatomy invoIved and shouId be done only under genera1 anesthesia.

This has not been of major consequence and has been alluded to by others.14 Cosmetic resuIt has been exceIIent, the incision being carefully placed in a skin fold. The depression in the cheek foIIowing removal of the gIand MS in and Ieaves IittIe if any facia1 asymmetry.

REFERENCES

CONCLUSIONS

EWING, J. Neoplastic Diseases, 4th cd. Philadelphia, 1940. W. B. Saunders Co. z. WILLIS, R. PathoIogy of Tumors. St. Louis, 1948.

I.

I. TotaI parotidectomy with preservation of the facia1 nerve has been performed on twentythree patients.

C. V. Mosby

162

Co.

TotaI 3. MCFAKLAND, the salivary

Parotidectomy

J. The mysterious mixed tumors glands. Surg., Gynec. e* O/w.,

for Mixed Tumor 9. .~~CCOKMXIC, I_. J., CAIILDWELL, E. \V. and ARSON, B. J. The surgical anatomy of the facial nerve. Surg. Gynec. P Oh., 80: 620-630, 1945. IO. SISTKUNK, W. E. hlixed tumors of the parotid gland. Minnesota Med., 4: 1555160, 192,. , ,. JANES, R. nl. Surgical treatment of tumors of the salivary glands. S. Clin. North America, 23:

of 76:

23-35, ‘943. 4. MCFARLAND, J. Studies of tumors of the parotid region. Surg., GJinec. e_+Ohst., 57: lo4-I 14, 1933. 5. HOUCK, J. R’. Tumors of the salivary glands. Surgery, 6: 565-584, 1939. 6. KOWAN, A. J., HOWM~D,J. hl., ROYSTEK, 11. D. and Ilorw, K. C. Tumors of the salivary glands. CUWW, 3: 445-458, 1950. ;. BAILEY, H. The treatment of tumours of the parotid gland with specia1 reference to total parotidectomy. &it. J. .!hg., 28: 337-346, 1941. 8. ~ZCWHORTEK, G. L. The relations of the superticial and deep lobes of the parotid gland to the ducts and to the facial nerve. Anat. Ret., 12: 14r)-154, 1017.

1429 ‘43% ‘943. tumors 12. DochEKT'I, k1. B. and ~IAUO, C. L!. Primary of the submaxillary gland with special reference to m&cd tumors. Surp., GJ-net. + Obs~., 74: 1033 1045, 1942. BELI., E.. T. Personal communication. ‘3. removal of tumors 01 ‘4. ~IAKTI~, II. The operative the p:trotitl salivary gland. SurqerJ-, 3 I : 670-682, l()j2.

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