- Email: [email protected]
WITHDRAWN: Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review
Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review Hosam Abd El-kader El Fol a, Mohmmed Jalal Beheiri b, Waleed Ali AL Zaqri b, * a b
Department of Surgical Oncology, Faculty of Medicine, Menofia University, Egypt Department of Oral & Maxillofacial Surgery, Faculty of Oral & Dental Medicine, Cairo University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 29 September 2014 Accepted 8 January 2015 Available online xxx
Purpose: Since of the 1940s, there has been wide controversy about the most effective surgical treatment for the primary benign parotid tumor. This review investigates the effectiveness and associated complications of superficial parotidectomy versus total conservative parotidectomy in the management of primary benign parotid tumors. Material and methods: An electronic search with restricted dates (1920e2014) and restricted language was performed in August 2014. Thirteen studies were included. In total, 2477 patients were enrolled in the 13 studies, with 1317 patients undergoing superficial parotidectomy and 391 patients undergoing total conservative parotidectomy; 769 patients treated with other surgical techniques were excluded. The maximum follow-up period varied between 2 and 24 years (mean 2.8 years). Results: The incidence of recurrence in the superficial parotidectomy patients ranged from 0% to 15% (mean 5.7%), whereas, in the total conservative parotidectomy patients it ranged from 0% to 16% (mean 3.03%). The incidence of the facial nerve paresis according to collected data in the superficial parotidectomy group ranged from 0% to 23% (mean 6.75%), whereas in the total conservative parotidectomy group it was 0%e45% (mean 15%). The incidence of facial nerve paralysis in the superficial parotidectomy group ranged from 0% to 3% (mean 0.8%), whereas in the total conservative parotidectomy group it was 0%e17 % (mean 4.4%). Conclusion: The results of this review suggest that superficial parotidectomy is superior to total conservative parotidectomy in the management of primary benign tumor in superficial lobes. In addition, superficial parotidectomy showed a minimal recurrence rate for benign tumor in superficial lobes. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Total conservative parotidectomy Superficial parotidectomy Facial nerve dysfunction Recurrence
1. Introduction Tumors of the salivary glands represent 3%e10% of all head and neck neoplasms (Foresta et al., 2014). Approximately 75%e85% of these neoplasms occur in the parotid gland, of which 70%e80% are benign (Woods et al., 1975; Batsakis, 1979; Eveson and Cawson, 1985; Spiro, 1986; Byrne and Spector, 1988). They include various lesions, the most common being pleomorphic adenoma, followed by adenolymphoma (Arshad, 2006). In adults, benign tumors of the parotid gland predominate over malignant tumors in a ratio of 3:1
* Corresponding author. 23 Suleiman Alfransaoi St. Old Cairo, Cairo City, Egypt. Tel.: þ20 1014436119. E-mail addresses: [email protected], [email protected] (W.A.A. Zaqri).
or 4:1 (Grage et al., 1961; Eneroth, 1971; Hugo et al., 1973; Woods et al., 1975; Spiro, 1986). Surgical resection is the treatment of choice for benign parotid neoplasms. Techniques for surgical resection of benign tumors include surgical enucleation, extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy, and total conservative parotidectomy. However, there still is controversy as to the best surgical procedure for the removal of benign parotid tumors (Witt, 2002; Guntinas-Lichius et al., 2006; Klintworth et al., 2010). In the first half of the 20th century, benign parotid tumors were often treated by enucleation. The tumor capsule was opened, and the tumor tissue was totally lifted out of the capsule (Rawson et al., 1950). With this technique, capsular structures were left in situ. As a result, tumor cells could be distributed over the operative field.
http://dx.doi.org/10.1016/j.jcms.2015.01.002 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
2
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
This means that the rate of tumor recurrence was relatively high. Some studies reported recurrence rates between 20% and 45% (Rawson et al., 1950; McFarland, 1936; Patey and Thackray, 1958). It was reported by Claus et al. that local recurrence takes place in at least one-third of the patients who undergo enucleation (Wittekindt et al., 2007). In October 2014, Witt et al. conducted a systematic review investigating the etiologies of parotid adenoma recurrence. They concluded that the most important causes of recurrence are enucleation with rupture and incomplete tumor excision at operation (Witt et al., 2014). In contrast to enucleation, extracapsular dissection (ECD) is a minimal margin surgical technique in which the tumor is removed with a 2- to 3-mm rim of healthy tissue without dissection of the facial nerve (Emodi et al., 2010). This technique has its disadvantages. It is a procedure for experienced surgeons, as the facial nerve is not controlled from the outset, and there is a risk of rupture of the tumor (Witt and Iacocca, 2012). When used in the case of large tumors, it may lead to complications such as facial paralysis and recurrence (Piekarski et al., 2004). Incomplete removal and recurrence often happen with ECD if pseudopodia and/or satellite nod€ren and Stauffer, 2007). ECD is not ules tumor are present (Zba recommended for the treatment of pleomorphic adenoma (Piekarski et al., 2004). Partial superficial parotidectomy (PSP) dissects less than the full facial nerve; the tumor is removed with 2 cm of normal parotid €ren et al., 2013). The main disadvantage of PSP is that the tissue (Zba main trunk of the facial nerve must be exposed to its bifurcation, during which it may be injured (Papadogeorgakis, 2011). Positive margins after surgery were found in 25% of tumors excised by PSP and ECP. PSP should be restricted to small lesions (<4 cm). Larger tumors have thinner capsules and abundant myxoid stroma, and are therefore more difficult to excise by PSP or ECP (Emodi et al., 2010). Identification and dissection of the facial nerve allowed en bloc removal of the adenomas together with a safety margin of parotid tissue. This led to a sharp decline in the recurrence rate and preservation the facial nerve integrity (Riad et al., 2011). Superficial parotidectomy (SP) is defined as the removal of the superficial lobe of the parotid gland. Total conservative parotidectomy (TCP) is the total removal of parotid tissue with sparing of the facial nerve (Arshad, 2006). Both TCP and SP are optimal surgical procedures that, if applied at the first surgery for pleomorphic sevic adenoma, provide almost 100% certainty of healing (Cau Vu cak and Masi c, 2014). The debate regarding the merits and shortcomings of these 2 techniques has been active since 1945. A literature review by Lazard et al. on surgical treatments for benign tumors of the superficial parotid lobe in adults concluded that the current literature did not provide reliable evidence for choosing between SP and TCP (Lazard et al., 2005). Therefore, the aim of the current systematic review is to investigate the effectiveness and complications of TCP versus SP for the treatment of primary benign parotid tumors based on the latest available evidence. 2. Materials and methods 2.1. Data sources and key words An electronic search was performed in August 2014 in the following data databases: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Alt Health Watch, Health Source: Consu-mer Edition, Health Source: Nursing/Academic Edition, CINAH, Scopus, Wily Online Library, and Electronic Journal Centre. Restriction was to dates from
1 January 1920 to 25 August 2014, and language was also restricted to English. The key words and their combinations used in the search included. 1 In PubMed: (((benign tumor) OR benign neoplasm))) OR pleomorphic adenoma [Title/Abstract]) AND (total conservative parotidectomy OR complete parotidectomy [Title/Abstract])) OR (superficial parotidectomy OR lateral parotidectomy [Title/Abstract]))) AND (facial nerve dysfunction OR recurrence) 293 articles were collected from this data base. 2 In Scopus: “benign tumor” (Article title, abstract, key word) AND “total conservative parotidectomy” (Article title, abstract, key word) OR “superficial parotidectomy” (Article title, abstract, key word) and “facial nerve dysfunction” OR recurrence (Article title, abstract, key word) (109 articles) in all years. 3 In Wily Online Library: benign tumor (in Article Titles) AND total conservative parotidectomy (in Abstract) OR superficial parotidectomy in (Abstract) AND facial nerve dysfunction or recurrence (in All Fields) (69 articles). A manual search of oral and maxillofacial surgery-related journals, including the International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial Surgery, Journal of Maxillofacial and Oral Surgery, was also performed. Relevant reviews on the subject and the reference lists of the studies identified were also scanned for possible additional studies. Moreover, online databases pro-viding information on clinical trials in progress was checked (http://clinical-trials.gov; http://www.centerwatch.com/ clinical-trials; http://www.clinicalconnec-tion.com).
2.2. Inclusion and exclusion criteria Inclusion criteria were as follows: (1) studies in human adults; (2) randomized controlled trials (RCTs), quasierandomized controlled trials, or retrospective studies; (3) studies investigating primary benign parotid tumors without any metastases; (4) comparison of SP and TCP techniques; and (5) assessment of facial nerve paralysis, facial nerve paresis, or recurrence, with their ratio. Exclusion criteria were as follows: (1) case reports, animal studies, in vitro studies, surveys, and review papers; (2) studies including pediatric patients; (3) studies on patients with locoregional recurrence, malignant tumors, and inflammatory diseases; (4) studies without sufficient input data; and (5) studies conducted only on 1 surgical technique. 2.3. Selection of relevant studies The 3 authors independently assessed the eligibility of all studies retrieved from the databases. Disagreements concerning the selected studies were resolved by discussion. The following data (when available) were extracted from the studies included in the final analysis: year of publication, study design, number of patients, follow-up, types of benign tumor, types of surgical treatment (SP and TCP), and postoperative complications (facial nerve pareses, facial nerve paralysis, and tumor recurrence). Authors were contacted for missing data when required. 2.4. Quality assessment A methodological quality rating was performed by combining the proposed criteria of the MOOSE statement (Stroup et al., 2000),
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
STROBE statements (Von Elm et al., 2007), and PRISMA (Moher et al., 2009), to verify the strength of scientific evidence in clinical decision making. The classification of the risk of potential bias for each study was based on the following 5 criteria: random selection in the population, definition of inclusion/exclusion criteria, report of follow-up, validated measurements, and statistical analysis. A study that included all of the criteria mentioned above was classified as low risk of bias, and a study that did not include 1 of these criteria was classified as a moderate risk of bias. When 2 or more criteria were missing, the study was considered as high risk of bias. 3. Results 3.1. Literature search
3
with 1317 patients in the superficial parotidectomy group, 391 patients in the total conservative parotidectomy group, and 769 patients in other surgical techniques excluded. The maximum followed-up period varied between 2 and 24 years (mean 2.8 years). Pleomorphic adenoma was the most common benign tumor in 1853 cases, followed by Warthin tumor in 54 cases; other benign tumors were 60 and the remaining of 510 parotid lesions were inflammatory or malignant lesions and were excluded. Concerning the SP and TCP groups, the operative approach had been standardized since 1987. In cases with a benign tumor within the lateral parotid tissue, superficial parotidectomy or total conservative parotidectomy was performed, that is, the facial nerve with all its peripheral branches was followed in an anterograde or retrograde preparation technique, depending on the site of the tumor. A closed suction drainage was instituted for 24e48 h (Guntinas-Lichius et al., 2004).
The study selection process is summarized in Fig. 1. The electronic search resulted in 473 entries. Thirteen additional articles were identified by hand-searching. After the initial screening of recorded articles, 80 articles were excluded because of duplication. Of the remaining 406 articles assessed, 356 were excluded by title and abstract because most of these articles were case reports, review studies, surveys, in languages other than English, or conducted on inflammatory and malignant diseases. For the remaining 50 articles, full text assessment led to the exclusion of 37 articles. Reasons for exclusion, absence of enough input data in the materials and methods section, or result and absence of a comparator group. Finally, a total of 13 published articles were included in this review.
Each trial was assessed for risk of bias; the scores are summarized in Table 2. Five studies (Martis, 1983; Corcione and Califano, 1990; Federspil et al., 1994; Van Hee et al., 1996; Marchesi et al., 2006) were judged to be at high risk of bias and 8 studies (Debets and Munting, 1992; Laskawi et al., 1996; Leverstein et al., 1997; Rehberg et al., 1998; Valentini et al., 2001; Guntinas-Lichius et al., 2004; Zernial et al., 2007; Riad et al., 2011) were considered at moderate risk of bias.
3.2. Description of included studies
3.4. Recurrence
Details of the data of the included studies are presented in Table 1. A total of 2477 patients were enrolled in the 13 studies,
A total of 1252 patients were enrolled in 10 studies (Martis, 1983; Corcione and Califano, 1990; Debets and Munting, 1992;
3.3. Quality assessment
Fig. 1. Study screening process.
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
4
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
Table 1 Studies comparing SP and TCP in management of primary benign parotid tumors. Demographic
Methodology
Outcome
Authors
Published
Patients (n)
Study design
Follow-up
Type of tumor PPA
W
Other
Martis Corcione and Califano Debets and Munting Federspil et al. Van Hee R. et al. Laskawi et al., Leverstein et al. Rehberg et al. Valentini et al. Guntinas-Lichius et al. Marchesi M et al. Zernial et al. Riad et al.
1983 1990 1992 1994 1996 1996 1997 1998 2001 2004 2005 2007 2011
263 55 150 166 30 475 246 372 100 295 88 73 164
Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st
10 Y e 7Y 10 Y e 63 M 95 M 1e24 Y 3Y 8Y e (8Y) 56.4 M
185 33 92 166 24 475 246 e 100 295 e 73 164
24 e 30 e e e e e e e e e e
44 e 11 e 6 e e e e e e e e
SP
TCP
SP
TCP
Fpa %
FP %
RE %
Fpa %
FP %
RE %
111 7 109 108 13 364 61 59 56 253 59 40 77
12 28 17 22 6 107 8 40 41 42 5 33 30
0 e e e e 1.4 0 3.3 0 23 10.3 16 e
e e e e e 1.4 0 e 0 3 0 e e
0 14 0 13 15 0.7 0 3 e e e 0 2.6
0 e e e e 3.3 0 9.7 0 45 20 42 e
e e e e e 17 0 e 0 5 0 e e
0 0 0 4.5 16 0 0.8 3 e e e 0 10
Ret.st, retrospective study; SP, superficial parotidectomy; TCP, total conservative parotidectomy; Fpa, facial paresis; FP, facial nerve paralysis; Re, recurrence; PPP, Parotid Pleomorphic adenoma; W, Warthin's tumor. Italics signifies Included Studies which meet the Eligibility Criteria.
Federspil et al., 1994; Van Hee et al., 1996; Laskawi et al., 1996; Leverstein et al., 1997; Rehberg et al., 1998; Zernial et al., 2007; Riad et al., 2011). The total of number of patients in the SP group was 949 and in the TCP group was 303 patients. The incidence of recurrence in the SP group ranged from 0% to 15% (mean 4.57%), whereas in the TCP group the incidence ranged from 0% to 16% (mean 2.4%). 3.5. Facial nerve paresis A total of 1291 patients were enrolled in 8 studies (Corcione and Califano, 1990; Laskawi et al., 1996; Leverstein et al., 1997; Rehberg et al., 1998; Valentini et al., 2001; Guntinas-Lichius et al., 2004; Marchesi et al., 2006; Zernial et al., 2007). The total number of patients in the SP group was 1003 and in the TCP group was 288. The incidence of facial nerve paresis in the SP group ranged from 0% to 23% (mean 6.75%), whereas in the TCP group the incidence ranged from 0% to 45% (mean 15%). 3.6. Facial nerve paralysis A total of 996 patients were enrolled in 5 studies (Laskawi et al., 1996; Leverstein et al., 1997; Valentini et al., 2001; Guntinas-Lichius et al., 2004; Riad et al., 2011) The SP group included 793 patients, whereas the TCP group included 384 patients. The incidence of facial nerve paralysis in the SP group ranged from 0% to 3% (mean
0.8 %), whereas in the TCP group the incidence ranged from 0% to 17 % (mean 4.4%). 4. Discussion Surgical treatments of benign tumors of the parotid gland comprise enucleation, enucleoresection, and superficial or total parotidectomy with preservation of the facial nerve, where possible (Valentini et al., 2001). In the past, the surgical management of parotid adenomas was unsatisfactory because of the excessive rate of permanent facial nerve palsy and recurrence (20%e45%). Janes and Bailey advocated identification of the main trunk of the facial nerve first, then dissection of the nerve, with removal of the superficial and/or deep lobe of the parotid. This became established as the appropriate treatment for benign and low-grade malignant lesions. With this technique, the permanent facial nerve paralysis became very rare, and recurrence rates declined sharply (Riad et al., 2011). SP and/or TCP with preservation of the facial nerve gives excellent results in the excision of the neoplastic mass, with very low case histories of lesions of the facial nerve (Valentini et al., 2001). In patients with benign tumor of the superficial lobe, either SP or TCP can be used (Lazard et al., 2005). Because all included studies had not stated the available data as SD necessary to perform a Meta analysis, we performed a review to summarize the effectiveness and complications of SP and TCP. The objective of
Table 2 Results of the quality assessment. Author
Martis C Corcione F et al., Debets and Munting Federspil et al. Van Hee R et al. Laskawi et al. Leverstein et al. Rehberg et al. Valentini et al., Guntinas-Lichius et al. Marchesi et al. Zernial et al. Riad et al.
Quality assessment of the included studies Randomization
Defined inclusion/ exclusion criteria
Follow-up
Validated measurement
Statistical analysis
Estimated potential risk of bias
No No No No No No No No No No No No No
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes NO Yes Yes NO Yes Yes Yes Yes Yes NO Yes Yes
No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
High High Moderate High High Moderate Moderate Moderate Moderate Moderate High Moderate Moderate
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
the present work was to study the effect of SP and TCP in management of benign tumor in the superficial lobe of the parotid gland, along with associated complications. The incidence of recurrent benign parotid adenoma, as reported in international literature over the last 20 years, shows a variance from 0% to 50%, with a progressive decrease in this percentage that currently stands between 1% and 2% (Valentini et al., 2001). In our study, the incidence of recurrence in the SP group ranged from 0% to 15% (mean 5.7%), whereas in TCP group it ranged from 0% to 16% (mean 3.03%). Lateral or total parotidectomy should be reserved for tumors of larger amounts or deeply located tumors, as both showed minimal postoperative complication such as recurrence (Corcione and Califano, 1990). In 3 studies, (Martis, 1983; Debets and Munting, 1992; Zernial et al., 2007), no recurrence in either the SP or TCP groups has been reported. In 3 studies (Van Hee et al., 1996; Rehberg et al., 1998; Riad et al., 2011), the recurrence rate in the SP group was lower than in the TCP group. In contrast, in 3 studies (Corcione and Califano, 1990; Federspil et al., 1994; Laskawi et al., 1996), the recurrence rate in the TCP was lower than that in the SP group. Only 1 study showed the same level of recurrence in both groups. Transitory facial nerve paresis remains a common postoperative occurrence. The incidence of the facial nerve paresis, according to collected data, ranged from 0% to 23% (mean 6.75%) the SP group, whereas in the TCP group, it ranged from 0% to 45% (mean 15%). In 3 studies (Martis, 1983; Leverstein et al., 1997; Valentini et al., 2001), no patients had reported facial nerve paresis in either the SP and or TCP groups. However, in 5 other studies (Laskawi et al., 1996; Rehberg et al., 1998; Guntinas-Lichius et al., 2004; Marchesi et al., 2006; Zernial et al., 2007), the SP group showed a lower facial paresis rate than the TCP group. Facial nerve paralysis is a quite frequent finding during the immediate postoperative period after parotidectomy (Silvonimi et al., 2010). The incidence of facial nerve paralysis in the SP group ranged from 0% to 3% (mean 0.8%). whereas in the TCP group it ranged from 0% to 17 % (mean 4.4%). In 3 studies, (Laskawi et al., 1996; Valentini et al., 2001; Marchesi et al., 2006), no patients had reported facial nerve paralysis in either the SP or TCP group. In contrast, in 2 studies (Laskawi et al., 1996; Guntinas-Lichius et al., 2004), the SP group had a lower facial nerve paralysis rate than the TCP group. 5. Conclusion Based on the results of the present study, we conclude the following: (1) for the management of primary benign tumors located in the superficial lobe, the superficial parotidectomy (SP) technique is more effective than the total conservative parotidectomy technique (TCP); and (2) in the management of benign parotid gland tumors, lower complication rates can likely be expected with SP compared to TCP. References Arshad AR: Benign parotid lesions: is near total parotidectomy justified? Ann Acad Med Singapore 35: 889e891, 2006 Batsakis JG: Clinical and pathological considerations. In: Tumors of the head and neck, 2nd edn. Baltimore: Williams & Wilkins, 1e74, 1979 Byrne MN, Spector JG: Parotid masses: evaluation, analysis and current management. Laryngoscope 98: 99e105, 1988 sevi Cau c Vu cak M, Masi c T: The incidence of recurrent pleomorphic adenoma of the parotid gland in relation to the choice of surgical procedure. Med Glas (Zenica) 11: 66e71, 2014 Corcione F, Califano L: Treatment of parotid gland tumors. Int Surg 75: 171e173, 1990 Debets JMH, Munting JDK: Parotidectomy for parotid tumors: 19-year experience from the Netherlands. Br J Surg 79: 1159e1161, 1992
5
Eneroth CM: Salivary gland tumors in the parotid gland, submandibular gland and the palatal region. Cancer 27: 1415e1418, 1971 Eveson JW, Cawson RA: Salivary gland tumours. A review of 2410 cases with particular reference to histological types, site, age and sex distribution. J Pathol 146: 51e58, 1985 €tzle W: Pleomorphic parotid adenomas and their Federspil PA, Federspil P, Scha recurrence. Head Neck Oncol 42: 28e35, 1994 Foresta E, Torroni A, Di Nardo F, de Waure C, Poscia A, Gasparini G, et al: Pleomorphic adenoma and benign parotid tumors: extracapsular dissection vs superficial parotidectomy review of literature and meta-analysis. Oral Maxillofac Surg 117: 663e676, 2014 Grage TB, Lober PH, Shahon DB: Benign tumors of the major salivary glands. Surgery 50: 625e633, 1961 Guntinas-Lichius O, Kick CJ, Peter K, Jungehuelsing M, Stennert E: Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 261: 143e146, 2004 Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E: Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 116: 534e540, 2006 Hugo NE, Mckinney P, Griffith BH: Management of the tumors of the parotid gland. Surg Clin North Am 53: 105e110, 1973 Klintworth N, Zenk J, Koch M, Iro H: Postoperative complications after extracapsular dissection of benign parotid lesions with particular reference to facial nerve function. Laryngoscope 120: 484e490, 2010 Laskawi RR, Schott T, Mirzaie-Petri M, Schroeder M: Surgical management of pleomorphic adenomas of the parotid gland: a follow up study of three methods. Oral Maxillofac Surg 54: 1176e1179, 1996 Lazard DS, Baujat B, Wagner I, Chabolle F: Surgery in superficial-lobe pleomorphic parotid adenoma. Fr Oto-Rhino-Laryngologie 87: 59, 2005 Leverstein H, Vander Wal JE, Tiwar RM, Vander Wal I: Snow GB: surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland. Br J Surg 84: 399e403, 1997 Marchesi M, Biffoni M, Trinchi S, Turriziani V, Campana FP: Facial nerve function after parotidectomy for neoplasms with deep localization. Surg Today 36: 308e311, 2006 Martis C: Parotid benign tumors: comments on surgical treatment of 263 cases. Int J Oral Surg 12: 211e220, 1983 McFarland J: Three hundred mixed tumors of the salivary glands of which 69 recurred. Surg Gynecol Obstet 63: 457e468, 1936 Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6: e1000097, 2009 Emodi Omri, Abu El-Naaj I, Gordin A, Akrish S, Peled M: Superficial parotidectomy versus retrograde partial superficial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma). J Oral Maxillofac Surg 68: 2092e2098, 2010 Papadogeorgakis N: Partial superficial parotidectomy as the method of choice for treating pleomorphic adenomas of the parotid gland. Br J Oral Maxillofac Surg 49: 447e450, 2011 Patey DH, Thackray AC: The treatment of parotid tumours in the light of a pathological study of parotidectomy material. Br J Surg 45: 477e487, 1958 ski K, Jeziorski A: Results of extracapsular Piekarski J, Nejc D, Szymczak W, Wron dissection of pleomorphic adenoma of parotid gland. J Oral Maxillofac Surg 62: 1198e1202, 2004 Rawson AJ, Howard JM, Royster HP, Horn Jr RC: Tumors of the salivary glands: a clinicopathological study of 160 cases. Cancer 3: 445e458, 1950 Rehberg E, Schroeder HG, Kleinsasser O: Surgery in benign parotid tumors: individually adapted or standardized radical interventions? Laryngorhinootologie 77: 283e288, 1998 Riad MA, Abdel-Rahman H, Board G, Ezzat WF, Adly A, Dessouky O, et al: Variables related to recurrence of pleomorphic adenomas: outcome of parotid surgery in 182 cases. Laryngoscope 121: 1467e1472, 2011 Silvonimi A, Pulkkinen J, Grenman R: Parotidectomy in the treatment of pleomorphic adenomadanalysis of long-term results. Acta Oto-Laryngologica 130: 1300e1305, 2010 Spiro RH: Salivary neoplasm: overview of a 35-experience with 2807 patients. Head Neck Surg 8: 177e184, 1986 Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al: Metaanalysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA 283: 2008e2012, 2000 Valentini V, Fabiani F, Perugini M, Vetrano S, Iannetti G: Surgical techniques in the treatment of pleomorphic adenoma of the parotid gland: our experience and review of literature. J Craniofac Surg 12: 565e568, 2001 Van Hee R, Misset M, Ysebaert D, Van de Heyning P, Koekelkoren E, Claes L, et al: Surgical treatment of benign tumours of the salivary glands. Acta Chir Belg 96: 161e164, 1996 Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP: STROBE initiative: the strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370: 1453e1457, 2007 Witt RL: The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 112: 2141e2154, 2002
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
6
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
Witt LR, Iacocca M: Comparing capsule exposure using extracapsular dissection with partial superficial parotidectomy for pleomorphic adenoma. Am J Otolaryngol Head Neck Med Surg 33: 581e584, 2012 €ren P: Etiology and Witt RL, Eisele DW, Morton RP, Nicolai P, Poorten VV, Zba management of recurrent parotid pleomorphic adenoma. Laryngoscope, Oct 7, 2014 Wittekindt C, Streubel K, Arnold G, Stennert E, Guntinas-Lichius O: Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 29: 822e828, 2007 Woods JE, Chong GC, Beahrs OH: Experience with 1360 primary parotid tumours. Am J Surg 130: 460e462, 1975
€ren P, Stauffer E: Pleomorphic adenoma of the parotid gland: histopathologic Zba analysis of the capsular characteristics of 218 tumors. Head Neck 29: 751e757, 2007 €ren P, Poorten VV, Witt RL, Woolgar JA, Shaha AR, Triantafyllou A, et al: PleoZba morphic adenoma of the parotid: formal parotidectomy or limited surgery? Am J Surg 205: 109e118, 2013 €rle F, Risick C, Wiltfang J: Long-term recurrence Zernial O, Springer IN, Warnke P, Ha rate of pleomorphic adenoma and postoperative facial nerve paresis in parotid surgery. J Craniomaxillofac Surg 35: 189e192, 2007
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review Hosam Abd El-kader El Fol a, Mohmmed Jalal Beheiri b, Waleed Ali AL Zaqri b, * a b
Department of Surgical Oncology, Faculty of Medicine, Menofia University, Egypt Department of Oral & Maxillofacial Surgery, Faculty of Oral & Dental Medicine, Cairo University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 29 September 2014 Accepted 8 January 2015 Available online xxx
Purpose: Since of the 1940s, there has been wide controversy about the most effective surgical treatment for the primary benign parotid tumor. This review investigates the effectiveness and associated complications of superficial parotidectomy versus total conservative parotidectomy in the management of primary benign parotid tumors. Material and methods: An electronic search with restricted dates (1920e2014) and restricted language was performed in August 2014. Thirteen studies were included. In total, 2477 patients were enrolled in the 13 studies, with 1317 patients undergoing superficial parotidectomy and 391 patients undergoing total conservative parotidectomy; 769 patients treated with other surgical techniques were excluded. The maximum follow-up period varied between 2 and 24 years (mean 2.8 years). Results: The incidence of recurrence in the superficial parotidectomy patients ranged from 0% to 15% (mean 5.7%), whereas, in the total conservative parotidectomy patients it ranged from 0% to 16% (mean 3.03%). The incidence of the facial nerve paresis according to collected data in the superficial parotidectomy group ranged from 0% to 23% (mean 6.75%), whereas in the total conservative parotidectomy group it was 0%e45% (mean 15%). The incidence of facial nerve paralysis in the superficial parotidectomy group ranged from 0% to 3% (mean 0.8%), whereas in the total conservative parotidectomy group it was 0%e17 % (mean 4.4%). Conclusion: The results of this review suggest that superficial parotidectomy is superior to total conservative parotidectomy in the management of primary benign tumor in superficial lobes. In addition, superficial parotidectomy showed a minimal recurrence rate for benign tumor in superficial lobes. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Total conservative parotidectomy Superficial parotidectomy Facial nerve dysfunction Recurrence
1. Introduction Tumors of the salivary glands represent 3%e10% of all head and neck neoplasms (Foresta et al., 2014). Approximately 75%e85% of these neoplasms occur in the parotid gland, of which 70%e80% are benign (Woods et al., 1975; Batsakis, 1979; Eveson and Cawson, 1985; Spiro, 1986; Byrne and Spector, 1988). They include various lesions, the most common being pleomorphic adenoma, followed by adenolymphoma (Arshad, 2006). In adults, benign tumors of the parotid gland predominate over malignant tumors in a ratio of 3:1
* Corresponding author. 23 Suleiman Alfransaoi St. Old Cairo, Cairo City, Egypt. Tel.: þ20 1014436119. E-mail addresses: [email protected], [email protected] (W.A.A. Zaqri).
or 4:1 (Grage et al., 1961; Eneroth, 1971; Hugo et al., 1973; Woods et al., 1975; Spiro, 1986). Surgical resection is the treatment of choice for benign parotid neoplasms. Techniques for surgical resection of benign tumors include surgical enucleation, extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy, and total conservative parotidectomy. However, there still is controversy as to the best surgical procedure for the removal of benign parotid tumors (Witt, 2002; Guntinas-Lichius et al., 2006; Klintworth et al., 2010). In the first half of the 20th century, benign parotid tumors were often treated by enucleation. The tumor capsule was opened, and the tumor tissue was totally lifted out of the capsule (Rawson et al., 1950). With this technique, capsular structures were left in situ. As a result, tumor cells could be distributed over the operative field.
http://dx.doi.org/10.1016/j.jcms.2015.01.002 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
2
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
This means that the rate of tumor recurrence was relatively high. Some studies reported recurrence rates between 20% and 45% (Rawson et al., 1950; McFarland, 1936; Patey and Thackray, 1958). It was reported by Claus et al. that local recurrence takes place in at least one-third of the patients who undergo enucleation (Wittekindt et al., 2007). In October 2014, Witt et al. conducted a systematic review investigating the etiologies of parotid adenoma recurrence. They concluded that the most important causes of recurrence are enucleation with rupture and incomplete tumor excision at operation (Witt et al., 2014). In contrast to enucleation, extracapsular dissection (ECD) is a minimal margin surgical technique in which the tumor is removed with a 2- to 3-mm rim of healthy tissue without dissection of the facial nerve (Emodi et al., 2010). This technique has its disadvantages. It is a procedure for experienced surgeons, as the facial nerve is not controlled from the outset, and there is a risk of rupture of the tumor (Witt and Iacocca, 2012). When used in the case of large tumors, it may lead to complications such as facial paralysis and recurrence (Piekarski et al., 2004). Incomplete removal and recurrence often happen with ECD if pseudopodia and/or satellite nod€ren and Stauffer, 2007). ECD is not ules tumor are present (Zba recommended for the treatment of pleomorphic adenoma (Piekarski et al., 2004). Partial superficial parotidectomy (PSP) dissects less than the full facial nerve; the tumor is removed with 2 cm of normal parotid €ren et al., 2013). The main disadvantage of PSP is that the tissue (Zba main trunk of the facial nerve must be exposed to its bifurcation, during which it may be injured (Papadogeorgakis, 2011). Positive margins after surgery were found in 25% of tumors excised by PSP and ECP. PSP should be restricted to small lesions (<4 cm). Larger tumors have thinner capsules and abundant myxoid stroma, and are therefore more difficult to excise by PSP or ECP (Emodi et al., 2010). Identification and dissection of the facial nerve allowed en bloc removal of the adenomas together with a safety margin of parotid tissue. This led to a sharp decline in the recurrence rate and preservation the facial nerve integrity (Riad et al., 2011). Superficial parotidectomy (SP) is defined as the removal of the superficial lobe of the parotid gland. Total conservative parotidectomy (TCP) is the total removal of parotid tissue with sparing of the facial nerve (Arshad, 2006). Both TCP and SP are optimal surgical procedures that, if applied at the first surgery for pleomorphic sevic adenoma, provide almost 100% certainty of healing (Cau Vu cak and Masi c, 2014). The debate regarding the merits and shortcomings of these 2 techniques has been active since 1945. A literature review by Lazard et al. on surgical treatments for benign tumors of the superficial parotid lobe in adults concluded that the current literature did not provide reliable evidence for choosing between SP and TCP (Lazard et al., 2005). Therefore, the aim of the current systematic review is to investigate the effectiveness and complications of TCP versus SP for the treatment of primary benign parotid tumors based on the latest available evidence. 2. Materials and methods 2.1. Data sources and key words An electronic search was performed in August 2014 in the following data databases: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Alt Health Watch, Health Source: Consu-mer Edition, Health Source: Nursing/Academic Edition, CINAH, Scopus, Wily Online Library, and Electronic Journal Centre. Restriction was to dates from
1 January 1920 to 25 August 2014, and language was also restricted to English. The key words and their combinations used in the search included. 1 In PubMed: (((benign tumor) OR benign neoplasm))) OR pleomorphic adenoma [Title/Abstract]) AND (total conservative parotidectomy OR complete parotidectomy [Title/Abstract])) OR (superficial parotidectomy OR lateral parotidectomy [Title/Abstract]))) AND (facial nerve dysfunction OR recurrence) 293 articles were collected from this data base. 2 In Scopus: “benign tumor” (Article title, abstract, key word) AND “total conservative parotidectomy” (Article title, abstract, key word) OR “superficial parotidectomy” (Article title, abstract, key word) and “facial nerve dysfunction” OR recurrence (Article title, abstract, key word) (109 articles) in all years. 3 In Wily Online Library: benign tumor (in Article Titles) AND total conservative parotidectomy (in Abstract) OR superficial parotidectomy in (Abstract) AND facial nerve dysfunction or recurrence (in All Fields) (69 articles). A manual search of oral and maxillofacial surgery-related journals, including the International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial Surgery, Journal of Maxillofacial and Oral Surgery, was also performed. Relevant reviews on the subject and the reference lists of the studies identified were also scanned for possible additional studies. Moreover, online databases pro-viding information on clinical trials in progress was checked (http://clinical-trials.gov; http://www.centerwatch.com/ clinical-trials; http://www.clinicalconnec-tion.com).
2.2. Inclusion and exclusion criteria Inclusion criteria were as follows: (1) studies in human adults; (2) randomized controlled trials (RCTs), quasierandomized controlled trials, or retrospective studies; (3) studies investigating primary benign parotid tumors without any metastases; (4) comparison of SP and TCP techniques; and (5) assessment of facial nerve paralysis, facial nerve paresis, or recurrence, with their ratio. Exclusion criteria were as follows: (1) case reports, animal studies, in vitro studies, surveys, and review papers; (2) studies including pediatric patients; (3) studies on patients with locoregional recurrence, malignant tumors, and inflammatory diseases; (4) studies without sufficient input data; and (5) studies conducted only on 1 surgical technique. 2.3. Selection of relevant studies The 3 authors independently assessed the eligibility of all studies retrieved from the databases. Disagreements concerning the selected studies were resolved by discussion. The following data (when available) were extracted from the studies included in the final analysis: year of publication, study design, number of patients, follow-up, types of benign tumor, types of surgical treatment (SP and TCP), and postoperative complications (facial nerve pareses, facial nerve paralysis, and tumor recurrence). Authors were contacted for missing data when required. 2.4. Quality assessment A methodological quality rating was performed by combining the proposed criteria of the MOOSE statement (Stroup et al., 2000),
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
STROBE statements (Von Elm et al., 2007), and PRISMA (Moher et al., 2009), to verify the strength of scientific evidence in clinical decision making. The classification of the risk of potential bias for each study was based on the following 5 criteria: random selection in the population, definition of inclusion/exclusion criteria, report of follow-up, validated measurements, and statistical analysis. A study that included all of the criteria mentioned above was classified as low risk of bias, and a study that did not include 1 of these criteria was classified as a moderate risk of bias. When 2 or more criteria were missing, the study was considered as high risk of bias. 3. Results 3.1. Literature search
3
with 1317 patients in the superficial parotidectomy group, 391 patients in the total conservative parotidectomy group, and 769 patients in other surgical techniques excluded. The maximum followed-up period varied between 2 and 24 years (mean 2.8 years). Pleomorphic adenoma was the most common benign tumor in 1853 cases, followed by Warthin tumor in 54 cases; other benign tumors were 60 and the remaining of 510 parotid lesions were inflammatory or malignant lesions and were excluded. Concerning the SP and TCP groups, the operative approach had been standardized since 1987. In cases with a benign tumor within the lateral parotid tissue, superficial parotidectomy or total conservative parotidectomy was performed, that is, the facial nerve with all its peripheral branches was followed in an anterograde or retrograde preparation technique, depending on the site of the tumor. A closed suction drainage was instituted for 24e48 h (Guntinas-Lichius et al., 2004).
The study selection process is summarized in Fig. 1. The electronic search resulted in 473 entries. Thirteen additional articles were identified by hand-searching. After the initial screening of recorded articles, 80 articles were excluded because of duplication. Of the remaining 406 articles assessed, 356 were excluded by title and abstract because most of these articles were case reports, review studies, surveys, in languages other than English, or conducted on inflammatory and malignant diseases. For the remaining 50 articles, full text assessment led to the exclusion of 37 articles. Reasons for exclusion, absence of enough input data in the materials and methods section, or result and absence of a comparator group. Finally, a total of 13 published articles were included in this review.
Each trial was assessed for risk of bias; the scores are summarized in Table 2. Five studies (Martis, 1983; Corcione and Califano, 1990; Federspil et al., 1994; Van Hee et al., 1996; Marchesi et al., 2006) were judged to be at high risk of bias and 8 studies (Debets and Munting, 1992; Laskawi et al., 1996; Leverstein et al., 1997; Rehberg et al., 1998; Valentini et al., 2001; Guntinas-Lichius et al., 2004; Zernial et al., 2007; Riad et al., 2011) were considered at moderate risk of bias.
3.2. Description of included studies
3.4. Recurrence
Details of the data of the included studies are presented in Table 1. A total of 2477 patients were enrolled in the 13 studies,
A total of 1252 patients were enrolled in 10 studies (Martis, 1983; Corcione and Califano, 1990; Debets and Munting, 1992;
3.3. Quality assessment
Fig. 1. Study screening process.
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
4
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
Table 1 Studies comparing SP and TCP in management of primary benign parotid tumors. Demographic
Methodology
Outcome
Authors
Published
Patients (n)
Study design
Follow-up
Type of tumor PPA
W
Other
Martis Corcione and Califano Debets and Munting Federspil et al. Van Hee R. et al. Laskawi et al., Leverstein et al. Rehberg et al. Valentini et al. Guntinas-Lichius et al. Marchesi M et al. Zernial et al. Riad et al.
1983 1990 1992 1994 1996 1996 1997 1998 2001 2004 2005 2007 2011
263 55 150 166 30 475 246 372 100 295 88 73 164
Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st Ret.st
10 Y e 7Y 10 Y e 63 M 95 M 1e24 Y 3Y 8Y e (8Y) 56.4 M
185 33 92 166 24 475 246 e 100 295 e 73 164
24 e 30 e e e e e e e e e e
44 e 11 e 6 e e e e e e e e
SP
TCP
SP
TCP
Fpa %
FP %
RE %
Fpa %
FP %
RE %
111 7 109 108 13 364 61 59 56 253 59 40 77
12 28 17 22 6 107 8 40 41 42 5 33 30
0 e e e e 1.4 0 3.3 0 23 10.3 16 e
e e e e e 1.4 0 e 0 3 0 e e
0 14 0 13 15 0.7 0 3 e e e 0 2.6
0 e e e e 3.3 0 9.7 0 45 20 42 e
e e e e e 17 0 e 0 5 0 e e
0 0 0 4.5 16 0 0.8 3 e e e 0 10
Ret.st, retrospective study; SP, superficial parotidectomy; TCP, total conservative parotidectomy; Fpa, facial paresis; FP, facial nerve paralysis; Re, recurrence; PPP, Parotid Pleomorphic adenoma; W, Warthin's tumor. Italics signifies Included Studies which meet the Eligibility Criteria.
Federspil et al., 1994; Van Hee et al., 1996; Laskawi et al., 1996; Leverstein et al., 1997; Rehberg et al., 1998; Zernial et al., 2007; Riad et al., 2011). The total of number of patients in the SP group was 949 and in the TCP group was 303 patients. The incidence of recurrence in the SP group ranged from 0% to 15% (mean 4.57%), whereas in the TCP group the incidence ranged from 0% to 16% (mean 2.4%). 3.5. Facial nerve paresis A total of 1291 patients were enrolled in 8 studies (Corcione and Califano, 1990; Laskawi et al., 1996; Leverstein et al., 1997; Rehberg et al., 1998; Valentini et al., 2001; Guntinas-Lichius et al., 2004; Marchesi et al., 2006; Zernial et al., 2007). The total number of patients in the SP group was 1003 and in the TCP group was 288. The incidence of facial nerve paresis in the SP group ranged from 0% to 23% (mean 6.75%), whereas in the TCP group the incidence ranged from 0% to 45% (mean 15%). 3.6. Facial nerve paralysis A total of 996 patients were enrolled in 5 studies (Laskawi et al., 1996; Leverstein et al., 1997; Valentini et al., 2001; Guntinas-Lichius et al., 2004; Riad et al., 2011) The SP group included 793 patients, whereas the TCP group included 384 patients. The incidence of facial nerve paralysis in the SP group ranged from 0% to 3% (mean
0.8 %), whereas in the TCP group the incidence ranged from 0% to 17 % (mean 4.4%). 4. Discussion Surgical treatments of benign tumors of the parotid gland comprise enucleation, enucleoresection, and superficial or total parotidectomy with preservation of the facial nerve, where possible (Valentini et al., 2001). In the past, the surgical management of parotid adenomas was unsatisfactory because of the excessive rate of permanent facial nerve palsy and recurrence (20%e45%). Janes and Bailey advocated identification of the main trunk of the facial nerve first, then dissection of the nerve, with removal of the superficial and/or deep lobe of the parotid. This became established as the appropriate treatment for benign and low-grade malignant lesions. With this technique, the permanent facial nerve paralysis became very rare, and recurrence rates declined sharply (Riad et al., 2011). SP and/or TCP with preservation of the facial nerve gives excellent results in the excision of the neoplastic mass, with very low case histories of lesions of the facial nerve (Valentini et al., 2001). In patients with benign tumor of the superficial lobe, either SP or TCP can be used (Lazard et al., 2005). Because all included studies had not stated the available data as SD necessary to perform a Meta analysis, we performed a review to summarize the effectiveness and complications of SP and TCP. The objective of
Table 2 Results of the quality assessment. Author
Martis C Corcione F et al., Debets and Munting Federspil et al. Van Hee R et al. Laskawi et al. Leverstein et al. Rehberg et al. Valentini et al., Guntinas-Lichius et al. Marchesi et al. Zernial et al. Riad et al.
Quality assessment of the included studies Randomization
Defined inclusion/ exclusion criteria
Follow-up
Validated measurement
Statistical analysis
Estimated potential risk of bias
No No No No No No No No No No No No No
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes NO Yes Yes NO Yes Yes Yes Yes Yes NO Yes Yes
No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
High High Moderate High High Moderate Moderate Moderate Moderate Moderate High Moderate Moderate
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
the present work was to study the effect of SP and TCP in management of benign tumor in the superficial lobe of the parotid gland, along with associated complications. The incidence of recurrent benign parotid adenoma, as reported in international literature over the last 20 years, shows a variance from 0% to 50%, with a progressive decrease in this percentage that currently stands between 1% and 2% (Valentini et al., 2001). In our study, the incidence of recurrence in the SP group ranged from 0% to 15% (mean 5.7%), whereas in TCP group it ranged from 0% to 16% (mean 3.03%). Lateral or total parotidectomy should be reserved for tumors of larger amounts or deeply located tumors, as both showed minimal postoperative complication such as recurrence (Corcione and Califano, 1990). In 3 studies, (Martis, 1983; Debets and Munting, 1992; Zernial et al., 2007), no recurrence in either the SP or TCP groups has been reported. In 3 studies (Van Hee et al., 1996; Rehberg et al., 1998; Riad et al., 2011), the recurrence rate in the SP group was lower than in the TCP group. In contrast, in 3 studies (Corcione and Califano, 1990; Federspil et al., 1994; Laskawi et al., 1996), the recurrence rate in the TCP was lower than that in the SP group. Only 1 study showed the same level of recurrence in both groups. Transitory facial nerve paresis remains a common postoperative occurrence. The incidence of the facial nerve paresis, according to collected data, ranged from 0% to 23% (mean 6.75%) the SP group, whereas in the TCP group, it ranged from 0% to 45% (mean 15%). In 3 studies (Martis, 1983; Leverstein et al., 1997; Valentini et al., 2001), no patients had reported facial nerve paresis in either the SP and or TCP groups. However, in 5 other studies (Laskawi et al., 1996; Rehberg et al., 1998; Guntinas-Lichius et al., 2004; Marchesi et al., 2006; Zernial et al., 2007), the SP group showed a lower facial paresis rate than the TCP group. Facial nerve paralysis is a quite frequent finding during the immediate postoperative period after parotidectomy (Silvonimi et al., 2010). The incidence of facial nerve paralysis in the SP group ranged from 0% to 3% (mean 0.8%). whereas in the TCP group it ranged from 0% to 17 % (mean 4.4%). In 3 studies, (Laskawi et al., 1996; Valentini et al., 2001; Marchesi et al., 2006), no patients had reported facial nerve paralysis in either the SP or TCP group. In contrast, in 2 studies (Laskawi et al., 1996; Guntinas-Lichius et al., 2004), the SP group had a lower facial nerve paralysis rate than the TCP group. 5. Conclusion Based on the results of the present study, we conclude the following: (1) for the management of primary benign tumors located in the superficial lobe, the superficial parotidectomy (SP) technique is more effective than the total conservative parotidectomy technique (TCP); and (2) in the management of benign parotid gland tumors, lower complication rates can likely be expected with SP compared to TCP. References Arshad AR: Benign parotid lesions: is near total parotidectomy justified? Ann Acad Med Singapore 35: 889e891, 2006 Batsakis JG: Clinical and pathological considerations. In: Tumors of the head and neck, 2nd edn. Baltimore: Williams & Wilkins, 1e74, 1979 Byrne MN, Spector JG: Parotid masses: evaluation, analysis and current management. Laryngoscope 98: 99e105, 1988 sevi Cau c Vu cak M, Masi c T: The incidence of recurrent pleomorphic adenoma of the parotid gland in relation to the choice of surgical procedure. Med Glas (Zenica) 11: 66e71, 2014 Corcione F, Califano L: Treatment of parotid gland tumors. Int Surg 75: 171e173, 1990 Debets JMH, Munting JDK: Parotidectomy for parotid tumors: 19-year experience from the Netherlands. Br J Surg 79: 1159e1161, 1992
5
Eneroth CM: Salivary gland tumors in the parotid gland, submandibular gland and the palatal region. Cancer 27: 1415e1418, 1971 Eveson JW, Cawson RA: Salivary gland tumours. A review of 2410 cases with particular reference to histological types, site, age and sex distribution. J Pathol 146: 51e58, 1985 €tzle W: Pleomorphic parotid adenomas and their Federspil PA, Federspil P, Scha recurrence. Head Neck Oncol 42: 28e35, 1994 Foresta E, Torroni A, Di Nardo F, de Waure C, Poscia A, Gasparini G, et al: Pleomorphic adenoma and benign parotid tumors: extracapsular dissection vs superficial parotidectomy review of literature and meta-analysis. Oral Maxillofac Surg 117: 663e676, 2014 Grage TB, Lober PH, Shahon DB: Benign tumors of the major salivary glands. Surgery 50: 625e633, 1961 Guntinas-Lichius O, Kick CJ, Peter K, Jungehuelsing M, Stennert E: Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 261: 143e146, 2004 Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E: Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 116: 534e540, 2006 Hugo NE, Mckinney P, Griffith BH: Management of the tumors of the parotid gland. Surg Clin North Am 53: 105e110, 1973 Klintworth N, Zenk J, Koch M, Iro H: Postoperative complications after extracapsular dissection of benign parotid lesions with particular reference to facial nerve function. Laryngoscope 120: 484e490, 2010 Laskawi RR, Schott T, Mirzaie-Petri M, Schroeder M: Surgical management of pleomorphic adenomas of the parotid gland: a follow up study of three methods. Oral Maxillofac Surg 54: 1176e1179, 1996 Lazard DS, Baujat B, Wagner I, Chabolle F: Surgery in superficial-lobe pleomorphic parotid adenoma. Fr Oto-Rhino-Laryngologie 87: 59, 2005 Leverstein H, Vander Wal JE, Tiwar RM, Vander Wal I: Snow GB: surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland. Br J Surg 84: 399e403, 1997 Marchesi M, Biffoni M, Trinchi S, Turriziani V, Campana FP: Facial nerve function after parotidectomy for neoplasms with deep localization. Surg Today 36: 308e311, 2006 Martis C: Parotid benign tumors: comments on surgical treatment of 263 cases. Int J Oral Surg 12: 211e220, 1983 McFarland J: Three hundred mixed tumors of the salivary glands of which 69 recurred. Surg Gynecol Obstet 63: 457e468, 1936 Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6: e1000097, 2009 Emodi Omri, Abu El-Naaj I, Gordin A, Akrish S, Peled M: Superficial parotidectomy versus retrograde partial superficial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma). J Oral Maxillofac Surg 68: 2092e2098, 2010 Papadogeorgakis N: Partial superficial parotidectomy as the method of choice for treating pleomorphic adenomas of the parotid gland. Br J Oral Maxillofac Surg 49: 447e450, 2011 Patey DH, Thackray AC: The treatment of parotid tumours in the light of a pathological study of parotidectomy material. Br J Surg 45: 477e487, 1958 ski K, Jeziorski A: Results of extracapsular Piekarski J, Nejc D, Szymczak W, Wron dissection of pleomorphic adenoma of parotid gland. J Oral Maxillofac Surg 62: 1198e1202, 2004 Rawson AJ, Howard JM, Royster HP, Horn Jr RC: Tumors of the salivary glands: a clinicopathological study of 160 cases. Cancer 3: 445e458, 1950 Rehberg E, Schroeder HG, Kleinsasser O: Surgery in benign parotid tumors: individually adapted or standardized radical interventions? Laryngorhinootologie 77: 283e288, 1998 Riad MA, Abdel-Rahman H, Board G, Ezzat WF, Adly A, Dessouky O, et al: Variables related to recurrence of pleomorphic adenomas: outcome of parotid surgery in 182 cases. Laryngoscope 121: 1467e1472, 2011 Silvonimi A, Pulkkinen J, Grenman R: Parotidectomy in the treatment of pleomorphic adenomadanalysis of long-term results. Acta Oto-Laryngologica 130: 1300e1305, 2010 Spiro RH: Salivary neoplasm: overview of a 35-experience with 2807 patients. Head Neck Surg 8: 177e184, 1986 Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al: Metaanalysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA 283: 2008e2012, 2000 Valentini V, Fabiani F, Perugini M, Vetrano S, Iannetti G: Surgical techniques in the treatment of pleomorphic adenoma of the parotid gland: our experience and review of literature. J Craniofac Surg 12: 565e568, 2001 Van Hee R, Misset M, Ysebaert D, Van de Heyning P, Koekelkoren E, Claes L, et al: Surgical treatment of benign tumours of the salivary glands. Acta Chir Belg 96: 161e164, 1996 Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP: STROBE initiative: the strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370: 1453e1457, 2007 Witt RL: The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 112: 2141e2154, 2002
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002
6
H.A.E.-k. El Fol et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
Witt LR, Iacocca M: Comparing capsule exposure using extracapsular dissection with partial superficial parotidectomy for pleomorphic adenoma. Am J Otolaryngol Head Neck Med Surg 33: 581e584, 2012 €ren P: Etiology and Witt RL, Eisele DW, Morton RP, Nicolai P, Poorten VV, Zba management of recurrent parotid pleomorphic adenoma. Laryngoscope, Oct 7, 2014 Wittekindt C, Streubel K, Arnold G, Stennert E, Guntinas-Lichius O: Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 29: 822e828, 2007 Woods JE, Chong GC, Beahrs OH: Experience with 1360 primary parotid tumours. Am J Surg 130: 460e462, 1975
€ren P, Stauffer E: Pleomorphic adenoma of the parotid gland: histopathologic Zba analysis of the capsular characteristics of 218 tumors. Head Neck 29: 751e757, 2007 €ren P, Poorten VV, Witt RL, Woolgar JA, Shaha AR, Triantafyllou A, et al: PleoZba morphic adenoma of the parotid: formal parotidectomy or limited surgery? Am J Surg 205: 109e118, 2013 €rle F, Risick C, Wiltfang J: Long-term recurrence Zernial O, Springer IN, Warnke P, Ha rate of pleomorphic adenoma and postoperative facial nerve paresis in parotid surgery. J Craniomaxillofac Surg 35: 189e192, 2007
Please cite this article in press as: El Fol HAE-k, et al., Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review, Journal of Cranio-Maxillo-Facial Surgery (2015), http:// dx.doi.org/10.1016/j.jcms.2015.01.002