Surgical management of Warthin tumor: long-term follow-up of 224 patients from 2002 to 2018.

PURPOSE: Warthin tumors (WT) are the second most common benign parotid gland neoplasms. They can occur as synchronous or metachronous lesions in 6-10% of cases. This study aims to compare the complication rate in 224 patients who underwent extracapsular dissection (ECD) or superficial parotidectomy (SP) for the treatment of a WT. METHODS: This retrospective study was conducted at the Department of Maxillo-Facial Surgery at the University of Naples "Federico II" from February 2002 to December 2018 on a group of patients who underwent surgical treatment for WT. The type of surgical technique was chosen based on Quer's classification. The complications evaluated were facial nerve palsy, hematoma, Frey's syndrome, and bleeding. RESULTS: A total of 224 patients treated from 2002 to 2018 for Warthin tumor were included in the study. Two hundred elven had solitary tumors (94.1%) and 13 had multicentric lesions (5.8%), of which 9 cases presented synchronous lesions and 4 cases presented metachronous lesions. Extracapsular dissection (ECD) was performed in 130 patients (58.3% of cases) and superficial parotidectomy (SP) in the other 94 (41.7% of cases). CONCLUSIONS: We consider both surgical techniques as valid. In our opinion, it is essential to study each case based on Quer's Classification to obtain the best surgical outcome. Based on a lower observed rate of complications such as facial nerve palsy, Frey's syndrome, and bleeding, ECD seems to be the best option for the surgical treatment of Quer Class I lesions.

Selective Deep Lobe Parotidectomy vs Total Parotidectomy for Patients With Benign Deep Lobe Parotid Tumors.

Importance: Limited literature exists on surgical outcomes after selective deep lobe parotidectomy (SDLP) with preservation of superficial lobe for patients with benign deep lobe tumors. Objective: To compare the following factors for SDLP vs total parotidectomy for patients with benign tumors in the deep lobe: postoperative complications, including facial nerve paresis or paralysis, Frey syndrome, first bite syndrome, cosmetic defect, sialocele formation, and wound infection; and tumor control and recurrence. Design, Setting, and Participants: This case series included 273 adults who underwent SDLP (n = 177) or total parotidectomy (n = 96) at a single tertiary care institution for benign parotid tumors located in the deep lobe or deep lobe and parapharynx from January 1, 2000, to December 31, 2020. Exposure: Selective deep lobe parotidectomy vs total parotidectomy. Main Outcomes and Measures: Incidence of postoperative complications and tumor recurrence. Results: Among 273 patients (SDLP, 177 [65%]; 122 women [69%]; median age at surgery, 58 years [IQR, 46-67 years]; total parotidectomy, 96 [35%]; 57 women [59%]; median age at surgery, 59 years [IQR, 40-68 years]), the most common tumor was pleomorphic adenoma (SDLP, 128 of 177 [72%]; total parotidectomy, 62 of 96 [65%]). An abdominal dermal fat graft was less commonly performed for patients who underwent SDLP than those who underwent total parotidectomy (2 of 177 [1%] vs 20 of 96 [21%]; difference, -20% [95% CI, -28% to -11%]). The rate of great auricular nerve preservation was higher in the SDLP group than in the total parotidectomy group (84 of 102 [82%] vs 20 of 34 [59%]; difference, 24% [95% CI, 5%-42%]). No meaningful difference in length of hospital stay was found. The percentage of patients with House-Brackmann grade I immediately after surgery was 48% (85 of 177) in the SDLP group and 21% (20 of 96) in the total parotidectomy group (difference, 28% [95% CI, 16%-40%]). There were no clinically meaningful differences in rates of hematoma, sialocele, seroma, ear numbness, wound infection, or unplanned return to emergency department or operating room. The SDLP group reported a lower rate of Frey syndrome than the total parotidectomy group (1 of 137 [1%] vs 12 of 78 [15%]; difference, -15% [95% CI, -23% to -7%]), as well as a lower rate of facial contour defect (28 of 162 [17%] vs 25 of 84 [30%]; difference, -13% [95% CI, -24% to -1%]) and a higher rate of first bite syndrome (34 of 148 [23%] vs 7 of 78 [9%]; difference, 14% [95% CI, 5%-23%]). The percentage of patients with House-Brackmann grade I at their first follow-up visit was 67% (118 of 177) in the SDLP group compared with 49% (47 of 96) in the total parotidectomy group (difference, 17% [95% CI, 4%-30%]). There was no clinically meaningful difference in House-Brackmann grade after 1 year. Conclusions and Relevance: Findings of this case series study suggest that SDLP can be considered an effective and even superior technique for management of benign tumors in the deep parotid lobe. Advantages associated with SDLP include reduction in need for reconstruction for facial contour defect and reduction in complications, such as immediate facial nerve weakness and Frey syndrome. The incidence of first bite syndrome was higher in the SDLP group. Tumor control was not compromised by SLDP.

Evaluation of functional and aesthetic outcomes of free dermal fat graft versus superficial musculoaponeurotic system flap after superficial parotidectomy: randomized clinical trial.

BACKGROUND: Parotidectomy is the standard procedure for treatment of many parotid lesions; however, it has several drawbacks. Facial asymmetry and Frey's syndrome are the most annoying complications to patients. Insertion of interpositioning grafts into the parotidectomy bed can decrease these complications significantly. Free dermal fat graft (FDFG) and superficial musculoaponeurotic system (SMAS) flap have very promising results. This RCT aimed to compare these two techniques regarding functional and aesthetic outcomes. METHODS: Between February 2016 and October 2021, adult patients undergoing superficial conservative parotidectomy in a single centre for a benign indication were randomized into two equal groups using a closed envelope method. In one group, FDFG was inserted at the parotidectomy bed, whereas, in the other group, SMAS flap was performed. Preoperative, operative, and postoperative data were recorded and analysed. The primary outcome was the development of Frey's syndrome. RESULTS: Seventy-eight patients were randomized into two equal groups of 39 patients. There was no significant difference between the two groups regarding development of Frey's syndrome. There was no significant statistical difference between study groups regarding demographic data, co-morbidities, parotid pathologies, specimen volumes, total operating time, and postoperative complications. A tendency for over correction was observed in FDFG and under correction in SMAS flap. There was no statistically significant difference between the study groups regarding the patients' aesthetic satisfaction with the majority displaying excellent satisfaction with no poor results. CONCLUSION: FDFG and SMAS flap are simple, rapid, and reliable procedures and are effective in improving both functional and aesthetic outcomes post-parotidectomy. They have comparable results; however, selection of either procedure can be determined according to patient and tumour characteristics. Registration number: NCT05452837 (http://www.clinicaltrials.gov).

Selective deep lobe parotidectomy via retroauricular hairline (Roh's) incision for deep lobe parotid pleomorphic adenoma.

OBJECTIVE: Deep lobe parotid tumour is commonly removed with the covering superficial lobe of parotid gland. Total or subtotal parotidectomy leads to an increase in surgical morbidity. This study evaluated recurrence and function after selective deep lobe parotidectomy via retroauricular hairline (Roh's) incision for pleomorphic adenoma. MATERIALS AND METHODS: Twenty-eight patients with deep lobe parotid pleomorphic adenomas underwent selective deep lobe parotidectomy with preservation of the superficial lobe and the facial lobe via Roh's incision. Each patient was evaluated with any complications, cosmetic and salivary functions and local recurrence. RESULTS: Superficial lobe-preserving surgery via Roh's incision was successfully applied to all patients without injury to the facial nerve and the Stensen's duct for a median operation time of 65 min. Facial nerve paralysis was found only temporarily in 9 (32%) patients, and other complications were minimal. None of the patients had postoperative Frey's syndrome. Salivary secretory function in the operated side was well preserved. No recurrence was found in the patients for a median follow-up of 94 months. CONCLUSIONS: Selective deep lobe parotidectomy via Roh's incision is a reliable option of treatment for deep lobe parotid pleomorphic adenoma.

Superficial musculoaponeurotic system flap in partial parotidectomy and clinical and subclinical Frey's syndrome. Cosmesis and quality of life.

BACKGROUND: Frey's syndrome (FS), facial depression, and noticeable scar may have an impact on patient's quality of life after a parotidectomy. The superficial musculoaponeurotic system (SMAS) flap has been used to ameliorate those effects. METHODS: Forty-seven consecutive parotidectomies were analyzed; SMAS flap was performed in 26 of them. We investigated clinical FS, subclinical FS, and cosmetic satisfaction, and compared SMAS flap versus cases where this was not done. RESULTS: By performing the SMAS flap, the occurrence of clinical FS was reduced; however, there was no significant difference. Nonetheless, there was a significant difference in the perspiration intensity in favor of the group with SMAS flaps. In the cases we studied, the cosmetic satisfaction was high, even though facial contour-filling techniques were not used. CONCLUSIONS: Provided that the intensity of sweating is the main factor affecting the quality of life after surgery in patients, performing a SMAS flap renders the intervention worthwhile.

Frey's syndrome: case report.

Frey's syndrome is characterized by facial sweating and flushing in the parotid area when saliva is stimulated. It usually results from damage to the auriculotemporal nerve during parotidectomy.

Abordaje periauricular en las lesiones de la glándula parótida / Parothid glan lesions incision aroud ear

Evaluar la posibilidad de resección de las lesiones de la glándula parótida por incisiones periauriculares (grupo I) y valorar las complicacionesin mediatas derivadas de esta técnica, resultados cosméticos y dolor posoperatorio, comparándolas con el abordaje preauricular-transcervical (grupo II). Los 61 pacientes, de ambos sexos, entre julio de 2006 a julio de 2009, fueron sometidos a este estudio prospectivo, aleatorizado doble ciego, evaluando dos grupos, categorizados grupo I yII, haciendo comparaciones en cuanto a dolor posoperatorio según la escala analógica de niveles de dolor, complicaciones relacionadas al nervio facial, posibilidad de resección indistintamente del tipo histológico, del lóbulo afectado, y por último, la satisfacción cosmética. Los 59 pacientes completaron este estudio, no obteniendo diferencias estadísticamente significativas en cuanto al dolor posoperatorio, ni en cuanto a las complicaciones, pero si en lo referido a la visualización de la cicatriz operatoria; 96% de los pacientes (grupo I), refirió satisfacción con el resultado cosmético en comparación con 65% del grupo II; siendo estadísticamente significante. No hubo diferencias en cuanto a la presentación de dolor ni complicaciones posoperatorias en cuanto al abordaje periauricular en comparación a los que se les realizó el abordaje preauricular-transcervical. Fue mayor la manifestación de satisfacción cosmética en el abordaje periauricular, la cual recomendamos, porque no produce dificultades técnicas, indistintamente del sexo, edad, tipo histológico o ubicación de la lesión dentro de la glándula parótida.

To evaluate the possibility of resection of the lesions of the parotid gland by the incisions around the ear (Group I) and assess immediate complications arising fromthis technique, the cosmetics results and the post operative pain, comparing them with the ahead ear - transcervical approach (Group II). In 61 patients of both sex, from July 2006 to July 2009, were subjected to this prospective study, and randomized double blind, evaluating the two groups, categorized group I and II, making comparisons on post operative by the analog levels of the pain, complications related to the facial nerve, possibility of resection regardless of the histological type, the affected lobe, and finally, the cosmetic satisfaction. The 59 patients that completed this study, no statistically significant differences we found in the post operative pain getting. There were no differences also on complications, but if in connection with the post operative scar, the 96%patients (Group I), spoke to us, their satisfaction with the cosmetic outcome compared with 65% of Group II; that being statistically significant. There was no differences as regards the presentation of the painor the post operating complications in the around ear compared to the ahead ear - transcervical approach. The manifestation of cosmetic satisfaction in around ear were approach, we recommend it because it does not produce technical difficulties, without any distinction of sex, age, histological type, or location into the parotid gland.

[Auriculo temporal nerve. Neuroanatomic bases of the Frey's syndrome]. / El nervio auriculotemporal. Bases neuroanatómicas del síndrome de Frey.

The aim of this study was to precise the relationships of the auriculotemporal nerve in the infratemporal and parotid regions. We realized micro-dissections of thirty-two infratemporal and parotid regions of human cadaver's formol-fixed. The pattern of origin was: one root: 15.4%, two roots: 73.1%, three roots: 11.5%. In all cases, the lateral root present the major diameter (2-2.5 mm). In those cases with two roots, these formed a neural loop round the middle meningeal artery in the 89.4% of the cases. The origin of the medial root was the posterior border of the inferior alveolar nerve. The median distance between the lateral root and the temporomandibular joint capsule was 1.5 mm, with asymmetric pattern: right: 2 mm (rank: 0-7 mm; ED: 1.90 mm); left: 1.25 mm (rank: 0-3 mm; ED: 0.88 mm). In 10 cases (31.3%) the lateral root was in direct contact with the articular capsule, with asymmetric pattern: left: 46.1%; right: 21%. The median distance between the superior aspect of the articular disk and the trunk of the auriculotemporal nerve in the posterior aspect of the temporomandibular joint was 10,5 mm (ED: 4.06 mm), with asymmetric pattern: right: 9 mm (rank: 5-18.0 mm; ED: 3.70 mm); left: 11.0 mm (rank: 3.0-20 mm; ED: 4.41 mm). We discussed the rol of this findings in the etiology of the Frey's syndrome.

Síndrome del nervio auriculotemporal en niños secundario a un parto instrumentado con fórceps / Auriculotemporal nerve syndrome in children secondary to a forceps delivery

No disponible

No disponible

Síndrome de Frey en la infancia / Frey´s sydrome in childhood

El síndrome de Frey o auriculotemporal se caracteriza por la aparición de episodios recurrentes de eritema facial y/o hiperhidrosis, localizados en el territorio del nervio auriculotemporal, que ocurre en respuesta a los estímulos gustatorios. Este cuadro es poco frecuente en la infancia. Presentamos el caso clínico de una niña de 4 años de edad que presentaba eritema sin hiperhidrosis en la mejilla izquierda tras la masticación

Frey's syndrome, also known as auriculotemporal syndrome is characterized by recurrent episodes of facial flushing and/or sweating along the distribution of the auriculotemporal nerve, that occurs in response to gustatory stimuli. The disorder is rare in children. We report a 4-year-old girl with flushing without hyperhidrosis in the left cheek on eating

Painful sweating.

OBJECTIVE: The authors report a case of spontaneous and gustatory facial pain and sweating. METHODS: The patient had frequent episodes of pain, sweating, and flushing bilaterally in the hairless skin of the ophthalmic and maxillary distributions of the trigeminal nerve. Gustatory stimuli (e.g., orange juice, pickled onions) reliably evoked episodes, but episodes also frequently came on spontaneously. The problem had begun during adolescence, about the time of topical treatment and then electrocauteries for facial warts. The patient reported benefit from tricyclic antidepressants, guanethidine, and trospium chloride (an anti-cholinergic quaternary amine used in Europe for urinary urgency). There was no pain or excessive sweating in other body areas, nor pain with exercise. RESULTS: Administration of edrophonium IV evoked pain and sweating, and ganglion blockade by IV trimethaphan eliminated pain and sweating and markedly attenuated responses to edrophonium. Trospium chloride also prevented edrophonium-induced pain and sweating. Bicycle exercise produced the same increment in forehead humidity as in a spontaneous episode but did not evoke pain. Tyramine infusion did not bring on pain or sweating, whereas iontophoretic acetylcholine administration to one cheek evoked pain and sweating bilaterally. Topical glycopyrrolate cream eliminated spontaneous, gustatory, and edrophonium-induced episodes. CONCLUSIONS: The findings indicate that facial pain and sweating can result from occupation of muscarinic cholinergic receptors after acetylcholine release from local nerves. The authors propose that after destruction of cutaneous nerves, aberrant regenerant sprouting innervates sweat glands, producing gustatory sweating as in auriculotemporal syndrome (Frey syndrome), and innervates nociceptors, producing pain.

Frey syndrome. A proposal for evaluating severity.

We aimed to establish the incidence of Frey's syndrome in patients that have been submitted to partial and total parotidectomy at a cancer-treating hospital in Mexico City and to propose a grading system to determine its severity. The incidence of Frey's syndrome in 77 patients (25 male and 52 female) under oncological follow-up due to parotid tumors was subjectively evaluated through clinical findings and objectively diagnosed through Minor's test. The positive hyperhydrotic areas were recorded and measured on transparent acetates. Numeric values were assigned according to clinical perception of symptomatology by the patients (0 for no perception and 1 for clinical recognition), extent of the affected area (1 if less than 2 cm; 2 if between 2.1 and 4 cm, and 3 if more than 4 cm), intensity and smell of sweat (3 if it was excessive or of unpleasant odor). Results were expressed as mild (if less than 4 points) or severe grades (if 4 or more points). Frey syndrome was objectively diagnosed in 28 patients (36%), although only 17 (22%) recognized to have clinical manifestations of this condition. There were 22 women (79%) and six men (21%). Of these, seventeen (61%) had been subjected to partial and eleven (39%) to total parotidectomy. Adjuvant radiotherapy had been employed in nine cases (32%). The cutaneous affected area in the whole group ranged from 0.7 to 29.8 cm(2) (mean 8.9 cm(2)), with a mean affected surface of 8.7+/-10.8 cm(2) for women and 9.0+/-8.8 cm(2) for men ( p > 0.05). Twelve cases were classified as mild and sixteen as severe. No significant differences were found between patients treated with partial vs. total parotidectomy or between patients treated with or without adjuvant radiotherapy. The incidence of Frey's syndrome in Mexican patients seems to be similar to those reported in other countries; however, the extent of hyperhydrosis is lower when compared to some European studies. Our proposal for evaluating this condition may be a helpful tool in assessing the incidence and severity among the diverse populations and it may be a useful tool to define more precisely the indications for treatment and to evaluate the available therapeutic methods according to the severity of the condition.

Prospective cohort study comparing subcutaneous and sub-superficial musculoaponeurotic system flaps in superficial parotidectomy.

OBJECTIVE: To compare subcutaneous and sub-superficial musculoaponeurotic system (SMAS) flaps with regard to aesthetic result and Frey's syndrome following superficial parotidectomy. SETTING: A tertiary care centre. METHODS: A prospective cohort study of 45 patients who underwent superficial parotidectomies for benign disease between 1991 and 1996. All 45 patients completed self-administered questionnaires. Questions regarding perception of a facial contour deformity, Frey's syndrome, and scar rating were included. A total of 28 patients agreed to further direct patient evaluation where starch-iodine testing, photographs of the facial scar and contour, and facial nerve assessment were performed. RESULTS: Overall aesthetic results were acceptable in both groups. Scar rating was consistently higher in the sub-SMAS cohort compared with the subcutaneous group. Similarly, facial contour was found to be superior in the sub-SMAS group. Facial nerve function was normal in both groups. The overall incidence of subjective Frey's syndrome on questionnaire was 45%; however, the incidence of objective Frey's syndrome by starch-iodine testing was higher at 65%. We did not find a significant difference in the incidence of Frey's syndrome between the subcutaneous and the sub-SMAS groups. CONCLUSIONS: Sub-SMAS flaps result in superior facial contours and incisional scars following superficial parotidectomy compared with the subcutaneous flap elevation technique. We found no difference between these flaps with regard to the incidence of Frey's syndrome.

[Treatment of Frey syndrome with intracutaneous injections of botulinum toxin]. / Behandling af Freys syndrom med intrakutane injektioner af botulinumtoksin.

In a prospective study, we have examined the efficacy of intracutaneous injections of botulinum toxin in Frey's syndrome. In a controlled study, the long term results after surgical treatment for parotid tumors were investigated in 98 consecutive patients. Patients, who reacted positive by Minor's iodine-starch test, and who had subjective complaints too, were offered treatment. A total of four patients entered the study. The affected area was visualised by Minor's iodine-starch test. The coloured areas were injected with botulinum toxin (Botox) 2.5 U/0.1 ml. We injected 0.5 U/cm2. The distance between each injections points was 1 cm. All patients became free of symptoms. The injections were given with little discomfort to the patients and no side effects. At the control one year after the injections three patients had minor recurrent complaints, which were treated successfully by reinjections. Botulinum toxin injections are thus safe and effective in the treatment of FS.

[Frey syndrome: diagnosis and treatment]. / Zespól Frey--diagnostyka i leczenie.

Observed lately increased of the Lucie Frey's syndrom occurance is related to advanced frequency of the parotid gland surgery, especially because of neoplasmic lesions of the gland. Symptoms which follow partial or total parotidectomy are very bothersome for patients and unfortunately they strengthening with a lapse of a time. For applied pharmacotherapy outcomes are in fact dubious. In this light the recently applicated clostridium botulinum toxin of type A deserves of special attention as patient therapeutic agent for Frey's syndrome because of very promising results which can last for several months and even years. At first discussing the anatomopatholophysiology as well as diagnostic tests. The authors present their own experience as well as results obtained in application of the botulin toxin for therapy of the Lucie Frey syndrome.