Parotid Gland Metastases of Cutaneous Squamous Cell Carcinoma of the Head: Occult Metastases Occurrence and Their Late Manifestation.

Cutaneous squamous cell carcinomas (cSCC) are malignant tumours with excellent prognosis unless nodal metastases develop. The aim of our study is to determine the prognostic significance of the clinical stage of parotid gland metastases and the incidence of occult cervical lymph node involvement in cSCC of the head. Our retrospective analysis includes 39 patients with cSCC parotid gland metastases, 15 of whom had concurrent cervical node involvement. In 32 patients, the lymph nodes manifested at stage N3b. A total of 26 patients were treated with parotidectomy, 9 patients received radiotherapy alone, and 4 received symptomatic therapy. The surgical treatment included either total conservative (21 cases) or superficial parotidectomy (5 cases) and neck dissection (therapeutic neck dissections in 11 cases and elective in 14 cases). In all cases, surgery was performed with sufficient tumour-free resection margins. Adjuvant radiotherapy was administered postoperatively in 16 patients. Occult metastases were present in 21% of cases after an elective neck dissection, but not in any case in the deep lobe of the parotid gland. The five-year overall survival and recurrence-free interval were 52% and 55%, respectively. Patients with the cN3b stage and G3 histological grade tend to have a worse prognosis, but not at a statistically significant level. The prognosis was not worse in patients with concurrent parotid and cervical metastases compared to those with metastases limited to the parotid gland only. The addition of adjuvant irradiation, in comparison to a single modality surgical treatment, was the only statistically significant prognostic factor that reduced the risk of death from this diagnosis (p=0.013). The extent of parotidectomy (partial vs. total) had no impact on either the risk of recurrence or patient prognosis. The combination of surgery with irradiation provides the best results and should be applied to all patients who tolerate the treatment. A partial superficial parotidectomy should be sufficient, with a minimum risk of occult metastasis in the deep lobe. Conversely, the relatively high incidence of occult neck metastases indicates that patients could likely benefit from elective neck dissection.

Utility of Applying Pressure Dressing Following Parotidectomy Compared to Conventional Dressing: A Benefit or Not?

BACKGROUND: Post-parotidectomy wound dressing techniques lack of robust evidence, creating variation in practice. The choice between conventional and pressure dressing is typically based on expert opinions and individual preferences and the anticipated benefits of reduced drainage and shorter drain retention in pressure dressing hasn't demonstrated yet. PURPOSE: The purpose of this study is to assess the advantage of pressure dressing following parotidectomy compared to conventional dressing. STUDY DESIGN, SETTING, SAMPLE: This study was an open-label randomized controlled trial recruiting the patients aged 18 and above undergoing parotidectomy at the Otolaryngology Department of King Chulalongkorn Memorial Hospital between March 2021 and September 2022. Our exclusion criteria were as following: (1) underwent parotidectomy combined with neck dissection, (2) prior irradiation to the parotid gland or head and neck region, (3) prior parotidectomy within the previous year, (4) consumption of anticholinergic medications, (5) bleeding disorders or coagulopathies. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The predictor variable was postoperative dressing, and subjects were randomly assigned to pressure or conventional dressing. MAIN OUTCOME VARIABLE(S): The primary outcome variables were drain output (ml) measured every 8 hours and reported in the term of total drain output and duration of drain use. The secondary outcome variables were post-parotidectomy complications (if any), complications from the pressure dressing and pain scores. COVARIATES: The covariates were underlying disease, smoking, alcohol drinking, types of parotidectomy (extension of surgery), and pathologic result. ANALYSES: The appropriate univariate and bivariate statistics were computed, and the level of statistical significance was set at P value < .05. RESULTS: A total of 40 patients were enrolled, with 20 in each group. Average age was 59.10 ± 10.60 years in the pressure dressing group and 55.70 ± 18.90 years in the conventional dressing group. Baseline characteristics were the same in both groups. The average volume of drain output in the pressure dressing group was 44.25 ± 25.20 ml, compared to 37.05 ± 22.74 ml in the conventional dressing group (P = .34). Moreover, the average duration of drain placement for the pressure dressing group was 27.65 ± 9.86 hours, while it was 26.90 ± 11.23 hours for the conventional group (P = .83). Notably, there were no significant differences between the two groups regarding sialocele and pain scores. Furthermore, no complications from the application of pressure dressing were observed. CONCLUSION AND RELEVANCE: Pressure dressing does not provide significant benefits over conventional dressing after parotidectomy concerning drain output, duration of drain placement, or surgical complications.

Basal cell adenoma and basal cell adenocarcinoma of the parotid gland: clinical findings and surgical outcomes in a single-institution study.

BACKGROUND: Basal cell adenoma (BCA) is a rare benign tumor within the salivary glands. Basal cell adenocarcinoma (BCAC), the malignant counterpart of BCA, is also an exceedingly rare tumor with very limited clinical studies conducted. This study aims to investigate the clinical characteristics, demographics, and surgical outcomes of patients diagnosed with BCA and BCAC within the parotid gland. METHODS: A retrospective analysis from May 2003 to August 2023 was performed for all patients undergoing parotidectomy for masses. Retrospective data on gender, age, tumor characteristics, and outcomes were collected. Surgical approaches, including negative margin attainment, capsule removal, and histological diagnosis, were also detailed. RESULTS: The study included 1268 patients who underwent parotidectomy, resulting in 81 cases of BCA and 7 cases of BCAC. BCA patients, with a mean age of 55.1 years, showed diverse age distribution and predominantly presented in the 50s. In BCAC cases, seven female patients exhibited a predominant location in the deep lobes. FNA revealed BCAC in three out of seven cases, and subsequent parotidectomy was performed, resulting in no observed recurrences or metastases. CONCLUSION: This study reports the largest number of BCA cases from a single institution and provides comprehensive insights into the demographics, tumor characteristics, and clinical outcomes of both BCA and BCAC. Although further research should be conducted, based on clinical follow-up results, appropriately including the capsule in the tumor excision indicates favorable outcomes, especially when the tumor size is not large.

Elective nodal dissection for cN0 intermediate-grade parotid mucoepidermoid carcinoma: A NCDB study.

PURPOSE: To determine the occult nodal disease rate and whether elective regional lymph node dissection (RLND) confers any 10-year overall survival (OS) in cN0 intermediate-grade mucoepidermoid carcinoma (MEC) of the parotid gland. MATERIALS & METHODS: The National Cancer Database was reviewed from 2004 to 2016 on adults with cT1-4aN0M0 intermediate-grade parotid MEC undergoing resection with/without RLND. Comparisons between patients with and without RLND were made. Occult nodal rate and 10-year overall survival (OS) were determined. RESULTS: Out of 898 included patients with cN0 intermediate grade parotid MEC undergoing elective RLND, the occult nodal rate was 7.6%. This was significantly different from low-grade (3.9%) and high-grade (25.7%) cN0 disease. When stratified by pT-classification, marginal differences were identified between low-grade and intermediate-grade tumors, whereas high-grade tumors demonstrated increased occult nodal disease with low T-stage (pT1-pT2, 20.4% vs. 5.1%) and high T-stage (pT3-pT4a, 32.1% vs. 17.6%). Patients undergoing elective RLND were more often treated at an academic facility (53.8% vs. 41.2%), had higher pT3-pT4 tumors (19.2% vs. 10.4%), and more frequently underwent total/radical parotidectomy (46.0% vs. 29.9%) with adjuvant radiation therapy (53.8% vs. 41.0%) Cox-proportional hazard modeling did not identify RLND, regardless if stratified by nodal yield or pT-classification, nor nodal positivity as significant predictors of 10-year OS. CONCLUSIONS: The occult nodal disease in intermediate-grade parotid MEC is low and similar to low-grade. Elective RLND may have a limited impact on OS, though its effect on locoregional control remains unknown. LEVEL OF EVIDENCE: III.

Partial superficial parotidectomy for pleomorphic adenoma of the parotid gland: Early post-operative outcomes.

INTRODUCTION: There has been historical controversy regarding the extent of resection in the management of pleomorphic adenomas. This study aims to evaluate the extent of surgery and short-term postoperative outcomes of partial superficial parotidectomy (PSP) for the management of pleomorphic adenomas at a tertiary, high-volume center. METHODS: A retrospective chart review of patients who underwent PSP was performed. Variables included demographics, pre-operative facial nerve function, operative techniques, postoperative complications/facial nerve function, and recurrence. RESULTS: 151 adults who underwent PSP for pleomorphic adenoma from January 1st, 2000 to December 31st, 2022 were identified. Median age was 55 (IQR 40-66) years with females representing 74 % of the cohort. Median tumor size at presentation was 1.8 (IQR 1.3-2.3) cm. Baseline facial nerve function was excellent for most patients (House-Brackmann I, 99 %). Most patients underwent a superficial inferior parotidectomy (88 %). Modified Blair incision (70 %) was the most common incision. Intraoperatively, the facial nerve was identified in 149 (99 %) patients. The main trunk was identified in 126 (85 %) patients. No patient had tumor spillage. Only two patients required parotid bed reconstruction. The most common complication was ear numbness (60 %). Postoperatively, 114 patients were House-Brackmann grade I at both preoperative and postoperative assessment, 8 went from grade I to II, and 1 went from grade VI to II (Bell's palsy that resolved to grade II following surgery). Median follow-up was 1(IQR 1-5) month. CONCLUSION: PSP is efficacious in the management of pleomorphic adenomas with preservation of facial nerve function, and minimal post-operative complications. Future study is needed to assess long term recurrence risk.

Case-tailored indicated extracapsular dissection versus "one-size-fits-all" nerve dissection: Has the bet been won?

OBJECTIVE: The aim of the study was to trace the development of surgical therapy in a large cohort, examine its changes at one single institution that has been specializing in salivary gland pathologies over the last 22 years, and to determine the extent to which a possible shift in the surgical therapy of parotid benign tumors towards less radical methods was correlated with a change in the incidence of facial palsy and Frey's syndrome. STUDY DESIGN: Retrospective clinical study. METHODS: A retrospective evaluation of the records of all patients treated for benign parotid tumors at a tertiary referral center between 2000 and 2022 was carried out. Surgical methods were classified into four groups: extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy and complete parotidectomy. RESULTS: A total of 4037 patients were included in the study. Our analysis demonstrated an increase in the total number of parotidectomies for benign lesions from 71 (2000) to 298 (2022), mostly due to the increase in extracapsular dissections (from 9 to 212). The increased performance of less radical surgery was associated with a significantly decreased incidence of perioperative complications. CONCLUSIONS: Our study showed that the increased performance of less radical surgery was associated with better functional outcomes over the years.

A Review of Surgical Incisions Used for the Excision of Benign Parotid Tumors.

OBJECTIVE: To provide surgical references for selecting appropriate parotidectomy incisions, reviewing modified approaches, incision designs, and associated complications. METHODS: We have systematically searched 5 medical literature databases examining parotidectomy incision designs and postoperative complications from 2008 to 2021. RESULTS: There are a total of 9 novel incision designs: 1) posterior auricular hairline incision (PAHI); 2) combined preauricular and retroauricular incision (CPRI); 3) V-shaped incision (VI); 4) N-shaped incision (NI); 5) postaural incision (PI); 6) preauricular crutch incision (PCI); and 7) endaural incision (EI). Simultaneously, there are a total of 8 postoperative complications: 1) infection; 2) salivary fistula; 3) facial nerve palsy/paresis; 4) ear lobule numbness; 5) Frey syndrome; 6) facial deformity; 7) hematoma; and 8) tumor reoccurrence. CONCLUSIONS: Over the last decade, a surge in modified parotidectomy incisions has been witnessed in clinical practice. This expansion is attributed to rapid technical advancements and a deeper understanding of anatomy and histopathology. These modified approaches contribute significantly to improving cosmetic outcomes, minimizing associated complications, and enhancing patient satisfaction.

Anatomical Insights on the Cervical Nerve for Contemporary Face and Neck Lifting: A Cadaveric Study.

BACKGROUND: Despite the significant roles it plays in the functions of the platysma and lower lip, the cervical branch of the facial nerve is often overlooked compared to other branches, but its consideration is critical for ensuring the safety of neck surgeries. OBJECTIVES: The aim of this study was to clarify the anatomical discrepancies associated with the cervical branch of the facial nerve to enhance surgical safety. METHODS: The study utilized 20 fresh-frozen hemiheads. A 2-stage surgical procedure was employed, beginning with an initial deep-plane facelift including extensive neck dissection, followed by a superficial parotidectomy on fresh-frozen cadavers. This approach allowed for a thorough exploration and mapping of the cervical nerve in relation to its surrounding anatomical structures. RESULTS: Upon exiting the parotid gland, the cervical nerve consistently traveled beneath the investing layer of the deep cervical fascia for a brief distance, traversing the deep fascia to travel within the areolar connective tissue before terminating anteriorly in the platysma muscle. A single branch was observed in 2 cases, while 2 branches were noted in 18 cases. CONCLUSIONS: The cervical nerve's relatively deeper position below the mandible's angle facilitates a safer subplatysmal dissection via a lateral approach for the release of the cervical retaining ligaments. Due to the absence of a protective barrier, the nerve is more susceptible to injuries from direct trauma or thermal damage caused by electrocautery, especially during median approaches.

Comparative study of optimal compression pressure between conventional Barton's dressing and prefabricate garment in parotidectomy patients.

Excessive compression after parotidectomy can lead to flap necrosis, while inadequate pressure can cause fluid accumulation. This study aimed to determine the optimal pressure and compression properties of different types of dressings. Initially, pressure measurements were taken for conventional Barton's dressing and a pre-fabricated facial garment. In the subsequent phase, patients were randomly assigned to receive one of three types of pressure dressings: conforming bandage Barton's dressing, elastic bandage Barton's dressing or pre-fabricated facial garment. The dressing types were randomly crossed over the following day. The mean pressure exerted by conventional Barton's dressing and the pre-fabricated facial garment was 15.86 and 14.81 mmHg, respectively. There was no significant difference in the proportion of optimal pressure among the three types of pressure dressing (p-values of 0.195, 0.555 and 0.089 at pre-auricular, angle of mandible and post-auricular sites, respectively). The pre-auricular area demonstrated the highest proportion of optimal pressure, while suboptimal pressure was noted at the angle of the mandible and post-auricular area. Dressing types had no effect on pressure stability (p = 0.37), and there was no significant difference in patient preference (p = 0.91). Conforming bandage Barton's dressing, elastic bandage Barton's dressing and pre-fabricated facial garment exhibit comparable compressive properties, with no significant difference in patient preference and pressure stability.

[Case of Tongue Cancer That Was Considered to Be a Metachronous Double Cancer with Parotid Gland Cancer].

In Japan, the incidence of double cancers is increasing due to the rise in cancer prevalence in the super-aging society, and the frequency is particularly high among patients with head and neck cancer. To the best of our knowledge, there has been only 1 reported case of metachronous double cancer with parotid gland cancer and tongue squamous cell carcinoma, and herein we report the outline of this case. The patient was a 70-year-old male with a smoking history. In 2017, a total parotidectomy and neck dissection for adenocarcinoma of the right parotid gland were performed at the otolaryngology department, followed by concurrent chemoradiotherapy as postoperative therapy. Pathological examination revealed adenocarcinoma NOS(pT4aN2bM0, Stage ⅣA). There was no recurrence or metastasis, and the patient was recovering well. However, in October 2022, the patient presented to the hospital with a chief complaint of pain at the right margin of the tongue. At the initial consultation, an ulcerative lesion with a slightly unclear boundary and maximum diameter of approximately 15 mm was observed on the right margin of the tongue. Since epithelialization was observed in some regions, it was diagnosed as intractable stomatitis and the patient was put under observation for the time being. With no signs of healing during the follow- up examination a month later and considering the possibility of malignant tumors, a total excision of tongue lesion was performed. Pathological examination revealed well-differentiated squamous cell carcinoma(pT1N0M0, Stage Ⅰ). Going forward, we plan to conduct careful follow-up observations with the possibility of further metachronous double cancer occurrences in mind.

Gland preservation with postauricular sulcus approach for benign parotid tumors.

Gland-preserving surgery has gained popularity for treating benign parotid tumors, offering potential benefits by preserving facial nerve function and salivary secretion while reducing complications. This study aims to evaluate the functional, cosmetic, and disease control outcomes of gland-preserving surgery via a postauricular sulcus incision. METHODS: An observational longitudinal investigation encompassed 46 patients undergoing gland-preserving surgery for benign parotid tumors via the postauricular sulcus incision approach. Patient assessments included cosmetic contentment, functional repercussions, and disease management throughout the follow-up. RESULTS: Predominantly, tumors were situated in the superficial lobe, with successful application observed in 8 instances (17%) within the deep lobe. Notably, no tumor recurrences were detected during the follow-up period. Postoperative pain remained minimal, accentuated by high patient satisfaction regarding the incision scar and facial symmetry. Furthermore, preservation of facial nerve functionality and salivary secretion was observed. CONCLUSION: Gland-preserving surgery via the postauricular sulcus incision technique exemplifies advantageous functional and cosmetic outcomes when addressing benign parotid tumors. This approach presents a secure and efficient alternative, facilitating effective local management.

Post-parotidectomy facial nerve rehabilitation outcomes: Comparison between benign and malignant neoplasms.

BACKGROUND: Facial nerve dysfunction can be a devastating trouble for post-parotidectomy patients. OBJECTIVE: To assess rehabilitation outcomes concerning patients with post-parotidectomy facial nerve dysfunction, comparing benign versus malignant neoplasms. METHODS: Prospective study enrolling adults who underwent parotidectomy with facial nerve sparing between 2016 and 2020. The Modified Sunnybrook System (mS-FGS) was used for facial assessments. Physiotherapy began on the first post-operative day with a tailored program of facial exercises based on Neuromuscular Retraining, to be performed at home 3 times/day. From the first outpatient consultation, Proprioceptive Neuromuscular Facilitation was added to the treatment of cases with moderate or severe facial dysfunctions. RESULTS: Benign and malignant groups had a statistically significant improvement in mS-FGS (p < 0.001 and p = 0.005, respectively). There was no significant difference between groups regarding treatment duration or number of physiotherapy sessions performed. The history of previous parotidectomy resulted in more severe initial dysfunctions and worse outcome. Age over 60 years and initially more severe dysfunctions impacted the outcome. CONCLUSION: Patients with benign and malignant parotid neoplasms had significant and equivalent improvement in postoperative facial dysfunction following an early tailored physiotherapy program, with no significant difference in the final facial score, treatment duration, or number of sessions required.

Chinese surgical robot-assisted surgery for parotid tumor: a case report.

Robotic surgery is known as the "third technological revolution" in the field of surgery, and is an important milestone in the development of modern surgery. However, our country's innovative surgical robot industry is still in its early stages, and it is only being utilized in certain surgical fields. To explore the effectiveness of the application of domestic surgical robot in oral and maxillofacial surgery, the author successfully completed a case of benign parotid tumor resection with the assistance of a domestic autonomous robot. The operation was successful, facial nerve function was preserved, and postoperative wound healing was good.

[Postauricular hairline plus temporal approach gasless full-endoscopic parotidectomy for tumors in deep lobe of parotid gland: a 16-case report].

To investigate the safety and feasibility of gasless total endoscopic resection of deep lobe parotid gland tumors via a postauricular hairline plus temporal approach. The approach was designed as: a 4 to 5 cm main incision was designed at the postauricular hairline, and a 0.5 cm auxiliary incision was designed in the temporal hairline. The operating cavity was established with the assistance of a special retractor. "Anterograde" dissection of the facial nerve was performed throughout the procedure, along with partial or total gland removal of the tumor. All 16 operations were successfully completed without conversion to open surgery. During the operation, the trunk and branches of the facial nerve were completely preserved, the tumor was completely removed, and the incision healed. Six patients had mild facial paralysis after operation, and recovered completely after 3 to 6 months. There was no salivary fistula, Frey syndrome, infection, or other complications. The postoperative incision was concealed and the aesthetic effect was good. The postauricular hairline plus temporal approach gasless total endoscopic parotidectomy is safe and feasible. This technique can achieve the complete dissection of the total trunk to the branches of the facial nerve, and has good access to the tumors located in any part of the parotid gland region. On the basis of radical resection of the tumor, it achieves minimally invasive and aesthetic improvement.

Digastric and sternocleidomastoid muscle flaps after conservative total parotidectomy for cancer: A CARE case report.

OBJECTIVE: To describe, according to the CARE guidelines, an easily reproducible technique using two local muscle flaps to reduce the unsightly retromandibular hollow left by total parotidectomy for cancer. CASE DESCRIPTION: A 40-year-old Caucasian male with T3N1M0 temporal skin melanoma was managed by skin resection, conservative total parotidectomy and ipsilateral level II-IV selective lymph-node dissection. Two rotational muscle flaps were taken from the ipsilateral posterior belly of the digastric and sternocleidomastoid muscles. Postoperative course was uneventful, with 3 days' hospital stay, without facial or spinal palsy. At 3 days, 3 months and 9 months postoperatively, the appearance of the parotid region was similar to the non-operated contralateral region. CONCLUSION: Easy to perform and without associated scars, the approach described here should be included in the armamentarium available to the head and neck surgeon to avoid an unsightly hollow after total parotidectomy for cancer, in an effort to improve quality of life.

Evaluation of a newly developed oral and maxillofacial surgical robotic platform (KD-SR-01) in head and neck surgery: a preclinical trial in porcine models.

Traditional open head and neck surgery often leaves permanent scars, significantly affecting appearance. The emergence of surgical robots has introduced a new era for minimally invasive surgery. However, the complex anatomy of the head and neck region, particularly the oral and maxillofacial areas, combined with the high costs associated with established systems such as the da Vinci, has limited the widespread adoption of surgical robots in this field. Recently, surgical robotic platform in China has developed rapidly, exemplified by the promise shown by the KangDuo Surgical Robot (KD-SR). Although the KD-SR has achieved some results comparable to the da Vinci surgical robot in urology and colorectal surgery, its performance in complex head and neck regions remains untested. This study evaluated the feasibility, effectiveness, and safety of the newly developed KD-SR-01, comparing it with standard endoscopic systems in head and neck procedures on porcine models. We performed parotidectomy, submandibular gland resection, and neck dissection, collected baseline characteristics, perioperative data, and specifically assessed cognitive workload using the NASA-TLX. None of the robotic procedures were converted to endoscopic or open surgery. The results showed no significant difference in operation time between the two groups (P = 0.126), better intraoperative bleeding control (P = 0.001), and a significant reduction in cognitive workload (P < 0.001) in the robotic group. In conclusion, the KD-SR-01 is feasible, effective, and safe for head and neck surgery. Further investigation through well-designed clinical trials with long-term follow-up is necessary to establish the full potential of this emerging robotic platform.

Mucosa-associated lymphoid tissue lymphoma at the parotid gland.

MALT (mucosa-associated lymphoid tissue) lymphomas are low-grade extra-nodal B-cell lymphomas that may involve various sites in the head and neck including the thyroid, salivary, and lacrimal glands. Development of MALT lymphoma in the head and neck is often associated with auto-immune diseases such as Sjögren syndrome or Hashimoto thyroiditis. Here, we report a case of a MALT lymphoma of the left buucal mucosa that likely arose in the parotid gland. The patient was successfully treated with surgical excision with chemotherapy and remained disease-free at the 10-year follow-up. Since it was rare in the head and neck region, we present this case.