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.

An analysis of health-related quality of life in children and adolescents after parotidectomy based on patient-reported outcomes.

PURPOSE: To assess health-related quality of life (HRQoL) and its influencing factors in these pediatric patients undergoing parotidectomy. METHODS: This was a cross-sectional study that included 37 children and adolescents (≤ 19 years) with parotid gland tumors who were treated in Sichuan Cancer Hospital between January 2006 and November 2021. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30). The Wilcoxon rank sum test was used to analyze the factors influencing patients' HRQoL. RESULTS: 37 children and adolescents were included in the study, including 22 cases of benign tumors and 15 cases of malignant tumors. All patients underwent surgery, and some patients with malignant tumors received radiotherapy or chemotherapy. Malignancy, permanent facial palsy, and Frey syndrome were associated with worse HRQoL in children and adolescents with parotid gland tumors. Radiotherapy and no cervical lymph node dissection were associated with worse HRQoL in pediatric patients with malignancy. The surgical approach of parotid is not a factor influencing HRQoL. CONCLUSION: Factors associated with HRQoL in children and adolescents with parotid gland tumors include pathological types, permanent facial palsy, and Frey syndrome. In addition, factors affecting patients with malignancy include lateral lymph node dissection and radiotherapy.

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.

The Minor's test in Frey syndrome treated with botulinum toxin: Methodology and efficacy.

In this paper, we aimed at methodologically presenting a video-case of Frey Syndrome occurred after parotidectomy, assessed by means of Minor's Test and treated with intradermic botulinum toxin A (BoNT-A) injection. Although largely described in the literature, a detailed explanation of both the procedures has not been previously elucidated. In a more original approach, we also highlighted the role of the Minor's test in identifying the most affected skin areas and new insight on the patient-tailored approach provided by multiple injections of botulinum toxin. Six months after the procedure, the patient's symptoms were resolved, and no evident signs of Frey syndrome were detectable through the Minor's test.

An Alternative Method to Prevent Frey Syndrome After Resection of Huge Masses in Parotis: De-epithelialized Skin Flap Use.

Frey syndrome is still a significant problem in postparotidectomy patients 6 to 18 months after surgery. The most accepted theory of the pathogenesis of Frey syndrome is the aberrant regeneration theory. Creating a barrier between the remnant parotid gland and the overlying skin prevents Frey syndrome. A 51-year-old female patient who developed pleomorphic adenoma in the parotid gland was operated. After superficial parotidectomy, a barrier between the underlying postganglionic parasympathetic nerves in the deep parotid gland and the overlying cutaneous tissue was created with a local skin flap to prevent Frey syndrome. The patient was successfully treated, and she was followed up to 5 years. No postoperative complications were observed. No signs of Frey syndrome were found in follow-up. This case highlights that local skin flaps can be an innovative natural method as it is a quick and simple method to create this barrier in the presence of expanded skin.

An update on extracapsular dissection for the management of parotid gland pleomorphic adenoma.

Superficial parotidectomy has been the gold standard for surgical removal of benign mobile parotid gland tumours. The comparatively newer technique of extracapsular dissection, which involves careful dissection of the tumour itself without the need for formal gland excision, has gained popularity in recent years. Tumours can be removed via smaller incision, and the technique reduces the risk of Frey's syndrome (gustatory sweating) and hollowing at the site of surgery. The risk of facial nerve damage can also be lower with extracapsular dissection. If done carefully, the incidence of tumour recurrence, particularly for pleomorphic adenomas, is comparable with formal parotidectomy. We provide a brief update overview of the current evidence for extracapsular dissection in the treatment of benign parotid tumours and include several meta-analyses which provide evidence for the safety of the technique. We have also included our audited results of over 100 recent extracapsular dissections, with 0% incidence of permanent facial nerve weakness, reported Frey's syndrome and recurrence rates over the last 5 years.

Auriculotemporal Frey syndrome not associated with surgery or diabetes: systematic review.

Patients who undergo salivary gland, neck, or facelift surgery or suffer from diabetes mellitus often develop Frey syndrome (also known as auriculotemporal syndrome or gustatory sweating). Frey syndrome has been occasionally reported to occur in subjects without history of surgery or diabetes but this variant of Frey syndrome has not been systematically investigated. We searched for original articles of Frey syndrome unrelated to surgery or diabetes without date and language restriction. Article selection and data extraction were performed in duplicate. Our systematic review included 76 reports describing 121 individual cases (67 males and 54 females) of Frey syndrome not associated with surgery or diabetes. The age at onset of symptoms was ≤ 18 years in 113 (93%) cases. The time to diagnosis was 12 months or more in 55 (45%) cases. On the other hand, an allergy evaluation was performed in half of the cases. A possible cause for Frey syndrome was detected in 85 (70%) cases, most frequently history of forceps birth (N = 63; 52%). The majority of the remaining 22 cases occurred after a blunt face trauma, following an auriculotemporal nerve neuritis or in association with a neurocutaneous syndrome. The cause underlying Frey syndrome was unknown in 36 cases.   Conclusion: Frey syndrome not associated with surgery or diabetes almost exclusively affects subjects in pediatric age and is uncommon and underrecognized. Most cases occur after forceps birth. There is a need to expand awareness of this pseudo-allergic reaction among pediatricians and allergists. What is Known: • Pre-auricular reddening, sweating, and warmth in response to mastication or a salivary stimulus characterize Frey syndrome. • It usually occurs after salivary gland surgery and in diabetes. What is New: • In children, Frey syndrome is rare, and most cases occur after a forceps-assisted birth. • In childhood, this condition is often erroneously attributed to food allergy.

Unilateral gustatory flushing in a teenager.

Unilateral gustatory flushing (also known as Frey syndrome) is presumed to be caused by injury to the autonomic component of the auriculotemporal nerve. It is important to distinguish the symptoms from those of food-induced allergy to avoid unnecessary investigation. The signs of Frey syndrome can persist for several years and can cause patients to feel self-conscious.

Treatment of Benign Lesion of Levels I or II of the Parotid Gland: Long Term Results of Partial Superficial Parotidectomy.

ABSTRACT: The correct surgical approach to benign parotid gland tumors is still matter of debate, it should be chosen considering the possibility of local recurrence or facial nerve complications in case of "not necessary" facial nerve dissection. In the era of minimally invasive surgery, more sparing approaches such as extracapsular dissection or partial superficial parotidectomy (PSP) are gaining popularity. The aim of the study is to present surgical results and long-term outcomes of PSP (level i or ii) in a large group of patients. Six hundred fifty-one patients who underwent parotid surgery between 2004 and 2020 were initially considered. Five hundred forty patients with benign lesions treated with PSP, enucleation, ECD were enrolled. Clinical features, surgical data, postoperative scarring, seroma, dehiscence, neuroma, outcomes as Frey syndrome, and delayed facial nerve dysfunction have been evaluated. 65.5% PSP, 25.2% enucleation, and 9.2% extracapsular dissection. No statistical difference in surgical time has been found (P 0.16). P  > 0.05 for seroma, neuroma, Frey syndrome, and facial palsy between different type of surgery. Frey syndrome in PSP: 6/135 (4.4%) in 2004 to 2012 and 2/219 (0.9%) in 2013 to 2020. The reduction between periods is significant (P < 0.04). Recurrence: 0.8% (3/354) for PSP patients, 3.4% (5/ 136) in enucleation and 10% (5/50) in ECD (P = 0.02). Partial superficial parotidectomy can be considered a minimally invasive and quick procedure with low complication rate. Our data seem to support this statement (large case series and long-term follow-up).

[Complications in the surgery of the parotid salivary glands. Causes, mechanisms of development, methods of prevention]. / Oslozhneniya v khirurgii okoloushnykh slyunnykh zhelez. Prichiny, mekhanizmy razvitiya, sposoby profilaktiki.

Operations for neoplasms of the parotid salivary gland require from the surgeon a deep knowledge of the anatomical and topographic features of this area and technical skill, which puts it in a number of «jewelry¼ operations that require patience and concentration. The review is devoted to the topic of specific postoperative complications after parotidectomy or subtotal resection of the gland. These include relapses of tumors, paralysis or paresis of facial muscles, Frey syndrome, salivary fistulas or sialocele, violation of skin sensitivity, soft tissue deformity. The review presents the frequency and causes of complications, mechanisms of their development, methods of prevention and elimination.

Control of Diabetic Gustatory Hyperhidrosis With Topical 20% Aluminum Chloride Hexahydrate.

Diabetic gustatory hyperhidrosis is a late sequela of diabetes and can have profound consequences. We report a case of diabetic gustatory hyperhidrosis controlled with topical aluminum chloride hexahydrate and support this as a first-line treatment. Aluminum chloride hexahydrate is a safe, effective, inexpensive and commercially available treatment.

Acellular dermal matrix for prevention of Frey's syndrome after superficial parotidectomy of benign tumors.

PURPOSE: To evaluate: 1) the efficacy of acellular dermal matrix (ADM) to prevent Frey's syndrome (FS) after superficial parotidectomy of benign tumors. 2) the effect of different follow-up intervals on the incidence of FS. METHODS: Fifty-five patients with benign parotid gland tumors underwent superficial parotidectomy were divided into two groups: Non-ADM group (n = 31, 56.3%) and ADM group (n = 24, 43.6%). The primary outcomes measure was the incidence of FS. The secondary outcomes were surgical site depression, infection, salivary sialocele, and salivary fistula. Subjective FS was evaluated using a clinical questionnaire submitted via WeChat at 3, 6, 12, 18, 24, and 32 months postoperatively. Objective FS was evaluated using Minor starch-iodine test at 6 and 12 months postoperatively. RESULTS: There was a statistically significant difference in the incidence of subjective and objective FS when ADM compared with Non-ADM groups (P<0.05). The respective incidence of subjective FS at 3, 6, 12, 18, 24, and 32 months was 4.2%, 8.3%,20.8%, 20.8%, 20.8%, 20.8% in ADM group and 3.2%, 9.7%, 29%, 38.7%, 45.2% in Non-ADM group. The incidence of objective FS after 6 and 12 months was 4.2%, 8.3% in ADM group and 8.3% (2/24), 38.7% (12/31) in Non-ADM group respectively. Five patients in ADM group and 1 patient in Non-ADM group developed sialocele, and all patients resolved with conservative management. Surgical site depression was significantly higher in the Non-ADM group (15/31) compared with (5/24) in ADM (P=0.049). No cases of immune rejection, infection, hematoma, or salivary fistula were observed in ADM group. CONCLUSIONS: The current study demonstrated that 1) ADM could reduce the incidence of FS in the patients undergoing superficial parotidectomy. 2) the peak onset of about 18 months appear to be acceptable follow-up for the development of FS.

Non-aesthetic uses of botulinum toxin in the head and neck.

INTRODUCTION: The use of botulinum toxin in the specialty of aesthetic surgery in the head and neck is well known. However, it has also been used for other conditions affecting the head and neck, and in recent years its use, as well as the number of relevant applications, has expanded enormously. REVIEW: This article presents a summary of the current range of uses in the laryngeal, pharyngeal, cervical, oromandibular and facial muscles and salivary glands. We highlight particular conditions focusing on dystonia (laryngeal, craniocervical, oromandibular and cervical), multiple system atrophy, migraines, facial nerve palsy, post-laryngectomy, cricopharyngeal dysphagia, Zenker's diverticulum, retrograde cricopharyngeal dysfunction disorder, sialorrhea and gustatory sweating (Frey's syndrome). CONCLUSION: This article should aid the ear, nose and throat surgeon garner knowledge about the range of uses for botulinum toxin in the head and neck.

Fat transfer after parotidectomy: fat resorption rates, aesthetic and functional outcomes of en-bloc fat graft versus lipofilling technique.

PURPOSE: Reconstruction of parotidectomy involves the correction of facial contour abnormalities and prevention from Frey Syndrome. Reconstruction of parotidectomy field with autologous fat has not been popular among head and neck surgeons due to unclear predictability of fat resorption rates. The aim of this paper is to compare the fat resorption rates between different fat transfer techniques using radiologic measurements and reviewing the aesthetic and functional outcomes. METHODS: We retrospectively reviewed medical records of patients, who underwent parotidectomy in Hacettepe University Hospital between 2015 and 2018. The aesthetic and functional outcomes of en-bloc fat graft and lipofilling techniques were compared among themselves, as well as with patients who had no reconstruction, using objective parameters. Fat resorption rates were compared using calculation of fat volumes obtained by MRI scans, 1 year after surgery. RESULTS: Among 77 patients, 26 underwent reconstruction with en-bloc fat graft (P-EBFG); 21 patients reconstruction with lipofilling technique (P-LFT), whereas 30 patients had no reconstruction of parotidectomy field (P-NR). In three groups, there was no statistically significant difference in mean resected parotid tissue volumes (mean 18 ± 10.8 cm3, p = 0.754). We found a significant difference in decreased presence of Frey Syndrome and increased satisfation rates of cosmetic appearance in P-EBFG and P-LFT, in comparison to P-NR (p < 0.001). There was no significant difference in fat resorption rates between P-EBFG (50.75 + 21.20%) and P-LFT (48.59 + 17.93%) (p = 0.771). CONCLUSION: Both en-bloc fat graft and lipofilling techniques have been found to be safe and to have similar fat resorption rates for reconstruction after parotidectomy.

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.

Frey syndrome-like developmental dysautonomia in a child with PHACE syndrome.

PHACE syndrome classically presents with a large, segmental facial infantile hemangioma (IH) associated with structural and vascular abnormalities involving the head and neck, heart, and eyes. We evaluated an infant who presented with ptosis caused by a clinically subtle, deep right-sided periorbital IH identified on MRI that also incidentally revealed hypoplasia of the right common carotid and right internal carotid arteries, supporting a diagnosis of PHACE syndrome. She subsequently developed acute-onset, transient right-sided facial erythema without anisocoria, triggered by feeding and emotional stress. We believe this represents a Frey syndrome-like developmental dysautonomia, previously unreported in association with PHACE syndrome, suggesting an associated defect in neurovascular embryogenesis.

Use of Parotid Gland Fascia in the Prevention of Frey Syndrome After Parotidectomy.

BACKGROUND: Superficial parotidectomy is standard surgical procedure for parotid gland tumor, and Frey syndrome and depressed deformity of the region are often seen as complications. In this study, we performed prevention of Frey syndrome by covering the residual parotid gland defect with the parotid gland fascia flap. METHOD: The subjects were 5 patients with parotid gland tumor. Tumor was localized in the inferior and superior poles of the parotid gland in 3 and 2 patients, respectively, and it was confirmed on preoperative diagnostic imaging that the tumor and parotid gland fascia were not present in close proximity. Through Lazy-S incision, main trunk of facial nerve was identified and conserved following the surgical procedure of normal superficial parotidectomy, and the superficial parotid gland containing tumor was elevated. A parotid gland fascia flap with a pedicle on the nasal side was prepared and the defect after superficial parotidectomy was covered with it. RESULTS: The facial nerve and resected parotid gland stump could be sufficiently covered with the parotid gland fascia flap in all patients. The mean duration of postoperative follow-up was 36 months (10 months-4 years and 5 months), and there were no complications such as tumor recurrence, Frey syndrome, salivary gland fistula, or severe concavity in the parotid region. CONCLUSION: Although application of the present procedure is limited to patients in whom the parotid gland fascia and tumor are not located in close proximity, it may be useful to prevent Frey syndrome because extension of incision is not necessary, the surrounding tissue is not sacrificed, the flap can be easily elevated, and the parotid gland stump can be sufficiently covered.