Review of surgical techniques and guide for decision making in the treatment of benign parotid tumors.

PURPOSE: Surgical treatment of benign parotid tumors has developed in the direction of less invasive procedures in recent years and has raised great debate about the best surgical approach. Aim of this article is to analyse anatomical and other factors that are important in selection of the appropriate surgical technique in treatment of benign parotid tumors. Furthermore, to discuss the risk of complications and recurrent disease according to selected operation. Finally, to define patient selection criteria to facilitate decision making in parotid surgery and become a guide for younger surgeons. METHODS: Literature review and authors' personal opinions based on their surgical experience. RESULTS: All possible surgical techniques for benign parotid surgery with advantages and disadvantages are being described. An algorithm with anatomical and other criteria influencing decision making in benign parotid surgery is presented. CONCLUSION: Surgeons nowadays have many options to choose from for benign parotid surgery. ECD is one of the many surgical techniques available in parotid surgery and can achieve excellent results with proper training and if used for proper indications. PSP is mainly indicated in large tumors of the caudal part of the PG (ESGS level II). SP represents a universal solution in parotid surgery and should be the first technique young surgeons learn. TP has only few but important indications in benign parotid surgery. Surgeons need to carefully consider the patient and his/her preoperative imaging as well as her or his own special expertise to select the most appropriate surgical technique.

Superficial or partial superficial parotidectomy for the treatment of primary benign parotid tumors.

OBJECTIVE: The extent of surgery in benign superficial parotid tumors has no strong evidence-based consensus. Partial superficial parotidectomy (PSP) is a popular choice among surgeons. We retrospectively evaluated the hypothesis that it carries similar efficacy and greater safety than superficial parotidectomy (SP). PATIENTS AND METHODS: Between 2010 and 2016, 84 patients with benign superficial parotid tumors were enrolled in the study. Deep lobe and recurrent tumors were excluded. The patients were treated by SP; (40 patients) or PSP; (44 patients). The operative and postoperative morbidity, tumor recurrence, operative time, and length of hospitalization were analyzed. RESULTS: There was no significant difference regarding patients or tumors in baseline data. PSP showed significantly shorter operative time (P = .022), and hospital stay (P = .001), as well as significantly lower frequencies of postoperative transient facial nerve paralysis and Frey's syndrome, (P = .042 for each). Permanent facial dysfunction was nonsignificantly greater in SP. No tumor recurrence was detected in either group after a median follow-up of 7 years. CONCLUSIONS: PSP is a quicker and less extensive procedure. It was associated with a shorter hospital stay and fewer complications especially transient facial paralysis and Frey's syndrome with a recurrence rate comparable to that of SP.

Evaluation of Salivary Function Post-Partial Superficial Parotidectomy.

Introduction: Parotid pleomorphic adenomas necessitate surgical intervention, with a growing emphasis on preserving salivary function post-surgery due to its critical role in maintaining oral health and overall quality of life. This study aims to evaluate a surgical method meticulously designed to preserve salivary function following partial superficial parotidectomy, utilizing Technetium-99m scintigraphy. Materials and Methods: This single-center prospective cohort study was conducted in Mashhad, Iran, between 2022 and 2023. The study encompassed 40 patients diagnosed with parotid pleomorphic adenomas, ages 20 to 64, undergoing partial superficial parotidectomy. The salivary function was evaluated using Technetium-99m scintigraphy three weeks post-operation. Results: Most participants underwent right parotid surgery (62.5%, n=25) instead of left parotid surgery (37.5%, n=15). The outcomes of the partial superficial parotidectomy indicated no complications during the three-week post-operative period. Saliva secretion rates on the operated side were preserved across the cohort. A significant difference in saliva secretion rates was observed between the operated and contralateral sides (P<0.01) for both right and left parotid surgery groups. No significant correlation was found between the time elapsed post-surgery and saliva secretion rates (P=0.48). Conclusion: Our study demonstrated that the superficial parotidectomy technique is notably effective when focused on preserving the salivary function of the deep parotid gland. Not only does it maintain saliva secretion on the operated side, but it also boasts an admirable safety profile. There were no recorded complications, and duct preservation was achieved in most instances.

Evaluation of the effectiveness of superficial parotidectomy and partial superficial parotidectomy for benign parotid tumours: a meta-analysis.

OBJECTIVE: To quantify the results of superficial parotidectomy (SP) and partial SP (PSP) for benign parotid tumours using a systematic evaluation method. METHODS: A systematic search of English and Chinese databases (PubMed, Web of Science, Cochrane Library, China Knowledge Network, Wanfang and Vipshop) was conducted to include studies comparing the treatment outcomes of SP with PSP. RESULTS: Twenty-three qualified, high-quality studies involving 2844 patients were included in this study. The results of this study showed that compared to the SP surgical approach, the PSP surgical approach reduced the occurrence of temporary facial palsy (OR = 0.33; 95% confidence interval [CI] 0.26-0.41), permanent facial palsy (OR = 0.28; 95% CI 0.16-0.52) and Frey syndrome (OR = 0.36; 95% CI 0.23-0.56) in patients after surgery, and the surgery operative time was reduced by approximately 27.35 min (95% CI - 39.66, - 15.04). However, the effects of PSP versus SP on salivary fistula (OR = 0.70; 95% CI 0.40-1.24), sialocele (OR = 1.48; 95% CI 0.78-2.83), haematoma (OR = 0.34; 95% CI 0.11-1.01) and tumour recurrence rate (OR = 1.41; 95% CI 0.48-4.20) were not statistically significant. CONCLUSION: Compared with SP, PSP has a lower postoperative complication rate and significantly shorter operative time, suggesting that it could be used as an alternative to SP in the treatment of benign parotid tumours with the right indications.

A modified method for minimizing damage to the marginal mandibular branch (MMB) during partial superficial parotidectomy(PSP): A retrospective study.

The aim of this study was to compare modified partial superficial parotidectomy (MPSP) with conventional partial superficial parotidectomy (CPSP) in a retrograde approach, and to determine whether MPSP can reduce the risk of injury to the MMB of the facial nerve and the rate of postoperative facial palsy. Patients with benign parotid gland tumors of the superficial lobe were included retrospectively in two groups: one group was treated with CPSP; the other group was treated with MPSP, in which the MMB was dissected in an anterograde direction or not dissected. The patients' sex and age, location of tumor, size of tumor (maximum tumor diameter), histopathological distribution, operative time, and incidence of postoperative facial nerve weakness were compared. There was no significant difference in operative time between the two groups (p = 0.913). There was a significant difference (p = 0.008) in postoperative facial nerve weakness, with temporary facial nerve weakness observed in 19 and five patients in the CPSP and MPSP groups, respectively. Furthermore, there was a significant difference (p = 0.009) in MMB weakness, with temporary MMB weakness observed in 15 and three patients in the CPSP and MPSP groups, respectively. There was no significant difference (p = 0.564) in the weakness of other branches between the two groups. All cases of paresis scored ≤3 on the House-Brackmann scale, and all cases of temporary facial nerve weakness resolved within 6 months of surgery. No patient developed permanent paralysis. Within the limitations of the study, it seems that modified partial superficial parotidectomy (MPSP) should be preferred over conventional partial superficial parotidectomy (CPSP) whenever appropriate.

Is extracapsular dissection for pleomorphic adenoma rather a euphemism for enucleation that jeopardises the intactness of the capsule?

The aim of this study was to compare several surgical modalities with respect to the incidence of positive margins and focal capsular exposure of pleomorphic adenoma of the parotid gland. The clinical records and histopathological findings of all patients who underwent parotidectomy for pleomorphic adenoma between 2006 and 2020 were retrospectively evaluated (n = 845). The lesion was removed by extracapsular dissection in 577 cases (68%) and facial nerve dissection in 268 (32%). Our analysis did not reveal a statistically significant difference between the examined modalities regarding positive margins (p=0.648) or capsular exposure (p=0.112). Recurrences were detected in 7/845 cases (0.82%) with a mean (range) follow-up time of 82.3 (6-183) months. The choice of surgical method does not seem to have a significant effect on the incidence of positive margins, or on the capsular exposure of a pleomorphic adenoma.

Comparison of postoperative complications and facial nerve recovery rates after conventional and partial superficial parotidectomy of benign parotid tumours: a prospective study.

The aim of this study was to compare postoperative complications and facial nerve (FN) recovery rates between conventional superficial parotidectomy (CSP) and partial superficial parotidectomy (PSP) as surgical treatment for benign parotid tumours. A prospective study was conducted on 55 consecutive patients who underwent either CSP (n=35) or PSP (n=20) for benign parotid tumours. The primary outcomes were FN injury, FN recovery rates, and Frey syndrome. Secondary outcomes were operative time, hospital stay, sialocele, haematoma, and auricular numbness. The degree of FN injury was evaluated at 1 week, 1, 3, 6, and 12 months postoperative using the House-Brackmann grading system. Frey syndrome was assessed using a subjective clinical questionnaire and objective Minor starch-iodine test. No patient in either group experienced permanent FN paralysis. There was a significantly higher incidence of temporary FN weakness in the CSP group (P=0.007). The respective FN recovery rates at 1, 3, 6, and 12 months were 60%, 88.6%, 94.3%, and 100% in the CSP group and 90%, 95%, 100%, and 100% in the PSP group. No significant difference was observed between the groups regarding the incidence of Frey syndrome, sialocele, and haematoma. The operative time and hospital stay were both shorter in the PSP group. Although the PSP is a more conservative procedure with significantly reduced FN injury, operative time, and hospital stay compared to CSP, the CSP procedure shows a comparable FN recovery rate to the PSP.

Do Benign Mass Lesions in the Superficial Lobe of Parotid Gland Influence Landmark-Based Search for Facial Nerve Trunk At Surgery?

OBJECTIVE: To assess the influence of benign mass lesions in the superficial lobe of parotid on the known anatomic landmarks for identifying the facial nerve trunk. METHOD: Patients with unilateral biopsy-proven benign mass lesions in the superficial parotid were selected for this observational study. During superficial/partial superficial parotidectomy, distance of the facial nerve trunk from each landmark was assessed using spring calliper and correlated with the lesion's volume (measured from the pre-operative imaging). At least two identifiers among tragal pointer (TP), posterior belly of digastric muscle (PBDM) and tympanomastoid suture (TMS) were considered. RESULTS: The study involved 32 patients. The lesions mostly involved the parotid tail (50%) and pretragal region (34.3%), and constituted of pleomorphic adenoma (~66%) and Warthin's tumor (~9%), the rest being various cysts and hamartomas. TP was universally uncovered, while PBDM and TMS were exposed in 26 and 25 patients, respectively. Average distances between the facial nerve trunk and TP, PBDM and TMS were 12.79 mm (SD=2.33), 9.78 mm (SD=1.21) and 7.58 mm (SD=1.33), respectively. Correlation coefficients between the lesion's volume and the distance of facial nerve from a given landmark were -0.11, 0.04 and -0.16 for TP, PBDM and TMS, respectively. CONCLUSION: TP was the most easily available landmark on surgical dissection, while PBDM was the most consistent and the least variable when volumetric data of the benign mass lesions in the superficial lobe of parotid were considered as a factor influencing the distance from the facial nerve trunk.

A meta-analysis of the pros and cons of partial superficial parotidectomy versus superficial parotidectomy for the treatment of benign parotid neoplasms.

OBJECTIVES: Salivary gland tumors are predominantly benign and frequently localized in the parotid gland (P). The treatment consists primarily of surgical removal; however, the appropriate extent remains a subject of debate. In suitable tumors, superficial parotidectomy (SP) may be substituted for less invasive partial superficial parotidectomy (PSP) (I C). This systematic review analyzed the available literature, comparing PSP and SP with regards to several postoperative outcome parameters (O). MATERIALS AND METHODS: Established medical databanks were screened for articles evaluating outcomes of PSP compared with SP, published between 1955 and 2019. These data were assessed by pooled risk and odds ratios via meta-analysis. RESULTS: 11 studies with 1272 patients were included. There was no significant difference in tumor recurrence between PSP and SP (primary outcome). Furthermore, no differences in the occurrence of permanent facial nerve paralysis (FNP), salivary fistula, great auricular nerve analgesia, or hematoma were observed between the groups. However, PSP displayed significantly reduced rates of transient FNP, Frey's syndrome, scar deformity, and xerostomia, as well as shorter surgical time, compared with SP (secondary outcomes). CONCLUSION: Based on these data, PSP can be recommended as a surgical technique for the treatment of superficially located, small, benign parotid tumors.

Extracapsular dissection versus partial superficial parotidectomy for the treatment of benign parotid tumours.

The purpose of this study was to compare the complications of patients treated for a benign parotid tumour (BPT) by extracapsular dissection (ECD) vs. partial superficial parotidectomy (PSP). A comprehensive literature investigation was conducted by searching electronic databases. A systematic review and meta-analysis of comparative studies were performed to assess ECD and PSP for the treatment of BPTs with fixed-effects models. The outcomes analysed were transient or permanent facial nerve injury, Frey syndrome, recurrence rate, infection, and salivary fistula/sialocele. A total of 1641 patients from seven studies (1120 ECD-treated and 521 PSP-treated patients) were included in this meta-analysis. Transient facial nerve injury (odds ratio (OR)=0.28, 95% confidence interval (CI): 0.11-0.71; p=0.008) and Frey syndrome (OR=0.12, 95% CI: 0.03-0.48; p=0.003) were less prevalent in the ECD group. The rates of permanent facial nerve injury (OR=0.77, 95% CI: 0.35-1.70; p=0.520), recurrence rate (OR=0.17, 95% CI: 0.02-1.75; p=0.14), infection (OR=0.70, 95% CI: 0.07-6.67; p=0.76), and salivary fistula/sialocele (OR=0.40, 95% CI: 0.06-2.66; p=0.350) were similar in both groups. Although there was a trend that ECD showed a reduced risk for complications, the present results are not sufficient to conclude that ECD is more beneficial than PSP.

[Partial superficial parotidectomy versus superficial parotidectomy for treatment of parotid benign tumors: evidence-based medicine analysis].

Objective:The aim of this study is to systematically assess the postoperative outcomes of partial superficial parotidectomy（PSP） and superficial parotidectomy（SP） by systematic literature review and Meta-analysis, and to provide a theoretical basis for the selection of the appropriate surgical approach in clinical process. Method:Relevant studies that compared the outcomes of PSP and SP for the parotid benign tumors were searched in Pubmed, CNKI and Wanfangdata databases, and Meta-analysis was performed using software RevMan 5.0. Result:24 studies were selected for the Meta-analysis. A total of 2 795 participants were included in those studies, of whom 1 301 underwent PSP and 1 494 underwent SP. The recurrence rates for PSP and SP were 1.14%（10 of 874） and 0.6%（6 of 993）, respectively. There were no statistically significant difference in recurrence rate between PSP and SP. The rates of transient facial nerve paresis for PSP and SP were 11.60%（122 of 1 052） and 27.37%（350 of 1 279）, respectively. The rates of permanent facial nerve paralysis for PSP and SP were 1.04%（6 of 579） and 4.46%（31 of 695）, respectively. The incidences of Frey's syndrome in PSP group and SP group were 9.20%（95 of 1 033） and 30.32%（409 of 1 349）, respectively. The rate of salivary fistulafor PSP and SP were 5.38%（37 of 688） and 11.25%（65 of 578）. PSP could reduce the risk for complications compared with SP. Conclusion:This systematic review with meta-analysis suggests that PSP has a similar recurrence rate as SP, but PSP can significantly reduce the postoperativecomplications.

Comparison of surgical techniques for benign parotid tumours: a multicentre retrospective study.

This study aimed to compare the outcomes of three surgical techniques for the treatment of patients with benign parotid tumours: superficial parotidectomy (SP; group 1), partial superficial parotidectomy (PSP; group 2), and ultrasonic scalpel-assisted minimal extracapsular dissection (US-MECD; group 3). Groups 1 and 2 received the conventional surgical technique, while group 3 underwent surgery with an ultrasonic scalpel. A total of 281 patients treated during 2012-2016 were included: 98 in group 1, 91 in group 2, and 92 in group 3. The mean surgical time and blood loss during surgery, as well as drainage time and amount, were significantly lower for US-MECD (P<0.01). The great auricular nerve and parotid fascia were both preserved with US-MECD (P<0.01), while the rate of capsule rupture with US-MECD was slightly higher than in the other groups (P>0.05). There was less transient facial nerve paralysis and Frey syndrome with US-MECD (P<0.01). No significant difference in wound infection, sialocele, or permanent facial nerve paralysis was observed among the three groups. Patients enrolled during 2012-2013 were selected to evaluate the recurrence rates, and no statistically significant differences were found among the groups. In conclusion, US-MECD showed similar effectiveness and fewer side effects than SP and PSP. The long-term effects of the new technique require further study.

[Retrospective study of partial superficial parotidectomy and superficial parotidectomy on superficial parotid benign tumor].

Objective:To compare the clinical effect between partial superficial parotidectomy (PSP) and superficial parotidectomy (SP) through a retrospective analysis and to provide evidence for the benign tumor surgical strategy. Method:According to different surgical strategies performed, 168 patients with superficial parotid benign tumor were reviewed and divided into PSP group and SP group. Clinical data was compared between two groups from different aspects, including operation condition, complications, recurrence rate, as well as parotid function. SPSS 22.0 software was used in statistical analysis. Result:PSP group has an average operative incision length of (6.65±1.17)cm, and average operation time of (82.25±11.56)min, while SP group is (10.86±1.65)cm and (121.42±17.32)min. So, compared with the SP group, PSP has obvious advantages in operation conditions (P<0.01). Furthermore, PSP group also presents an advantage over SP group in occurrence of postoperative complications (P<0.05), while there is no significant difference between two groups in palindromia rate (P>0.05). As for the maintenance of parotid gland functions, PSP group could retain most of parotid functions, but no function would be retained in SP group. Statistical analysis confirms the significance (P<0.05). Conclusion: Compared with SP, in PSP there is declined complication incidence but no increased palindromia recurrence. However, PSP has an apparent advantage on decreased surgical incision length, downscaled operation scope, reduced operation time and retained original functions of gland. All these advantages present the reliability and feasibility of PSP in treating superficial parotid benign tumor.

Margins for Benign Salivary Gland Neoplasms of the Head and Neck.

The proper ablation of any neoplasm of the head and neck requires the inclusion of linear and anatomic barrier margins surrounding the neoplasm. Extirpative surgery of the major and minor salivary glands is certainly no exception to this surgical principle. To this end, the selection and execution of the most appropriate ablative surgical procedure for a major or minor benign salivary gland neoplasm is an essential exercise in oral and maxillofacial surgery. Of equal importance is the intraoperative identification and preservation of the pseudocapsule surrounding the benign neoplasm. This article reviews these important elements specifically related to ablative surgery of benign neoplasms of the parotid, submandibular and minor salivary glands with strict attention to observed nomenclature.

Partial Superficial Parotidectomy With Retrograde Dissection of the Facial Nerve for Clinically "Benign" Parotid Tumors.

BACKGROUND: To review experience with partial superficial parotidectomy (PSP) and retrograde dissection of the facial nerve as a treatment for benign parotid tumors. METHODS: Retrospective cohort study of all patients presenting with a suspected benign primary parotid tumor undergoing parotid surgery. RESULTS: There were 214 cases retrieved. Postoperative facial nerve weakness occurred in 33% of patients; all were temporary. Increased extent of surgical resection (P < .001), deeper tumors (P = .05), and close tumor proximity to the facial nerve (P = .007) significantly correlated with postoperative facial weakness. The surgical margin was clear in 54%; 31% had capsule exposed in at least 1 point, and 13.5% had tumor at the margin. Cases with close proximity of tumor to facial nerve were more likely to have tumor at the margin (P = .034). CONCLUSION: Partial superficial parotidectomy with retrograde dissection is a suitable method for benign appearing parotid tumors.

Superficial parotidectomy versus partial superficial parotidectomy in treating benign parotid tumors.

The aim of the present study was to compare the outcomes of superficial parotidectomy (SP) and partial superficial parotidectomy (PSP) in treating benign parotid tumors. Individuals who had undergone SP or PSP between 2005 and 2008 were enrolled, the medical records were reviewed, and a questionnaire was created and mailed to the patients. For the statistical analysis, χ2 and non-parametric Mann-Whitney tests were used to analyze the variables. In total, 320 patients were included in the present study. Within the PSP group, immediate facial nerve weakness occurred in six patients (7.6%), and Frey's syndrome occurred in five (6.3%). Despite this, facial nerve function recovered fully during the follow-up, and recurrence was not identified. Within the SP group, Frey's syndrome occurred in 38 patients (15.8%), immediate facial nerve weakness in 55 patients (22.8%) and permanent facial nerve dysfunction in two patients (0.8%). However, no recurrence was evident. In total, 216 (67.5%) patients returned the questionnaire. Those with PSP demonstrated improved scores in the domains of appearance, facial contours, facial nerve function and Frey's syndrome. Compared with SP, PSP not only decreased the incidence of Frey's syndrome and transient facial nerve weakness, but also improved quality of life outcomes and guaranteed a low recurrence rate.

Partial Superficial Parotidectomy via Retroauricular Hairline Incision.

OBJECTIVES: The purpose of this study was to evaluate the usefulness of retroauricular hair line incision (RAHI) in partial superficial parotidectomy by comparison with modified Blair incision or facelift incision. METHODS: Medical records of 73 patients with benign parotid tumor who underwent partial superficial parotidectomy were retrospectively reviewed. Size and location of tumors, operative time, occurrence of facial nerve paralysis and Frey's syndrome, and cosmetic outcomes were compared among RAHI, facelift incision (FLI), modified Blair incision (MBI) groups. RESULTS: RAHI group showed better cosmetic results than FLI group or MBI group compared with other type of incisions (P<0.001, P<0.001, respectively). Among the 3 groups, there were no significant differences of operative time and location of tumor (P=0.377), size of tumor (P>0.999), occurrence of temporary or permanent facial nerve paralysis (P=0.745) and Frey's syndrome (P=0.940). CONCLUSION: Partial superficial parotidectomy can be done safely by RAHI in most cases of benign parotid tumor. Compared with MBI or FLI, RAHI has better cosmetic outcome with no increase of operative time or postoperative complications.

Partial Superficial Parotidectomy via Retroauricular Hairline Incision

OBJECTIVES: The purpose of this study was to evaluate the usefulness of retroauricular hair line incision (RAHI) in partial superficial parotidectomy by comparison with modified Blair incision or facelift incision. METHODS: Medical records of 73 patients with benign parotid tumor who underwent partial superficial parotidectomy were retrospectively reviewed. Size and location of tumors, operative time, occurrence of facial nerve paralysis and Frey's syndrome, and cosmetic outcomes were compared among RAHI, facelift incision (FLI), modified Blair incision (MBI) groups. RESULTS: RAHI group showed better cosmetic results than FLI group or MBI group compared with other type of incisions (P0.999), occurrence of temporary or permanent facial nerve paralysis (P=0.745) and Frey's syndrome (P=0.940). CONCLUSION: Partial superficial parotidectomy can be done safely by RAHI in most cases of benign parotid tumor. Compared with MBI or FLI, RAHI has better cosmetic outcome with no increase of operative time or postoperative complications.

Conservative Parotidectomy for Benign Parotid Tumors / 대한이비인후과학회지

Superficial parotidectomy is the most widely accepted form of the treatment for benign parotid tumors. But the risk of postoperative complications for the treatment of a benign condition cannot be ignored. Recent studies suggest that conservative parotidectomy (partial superficial parotidectomy or extracapsular dissection) might be the reliable option for the resection of benign parotid tumors. Conservative parotidectomy showed similar recurrence rate and lesser post operative complications than superficial parotidectomy.