Management ofparotidectomy with facialnerve preservation for thetreatment of pleomorphicadenoma of the parotid gland

Recently, the modified facelift incision (FLI) has gained increasing popularity for its cosmetic benefits in parotidectomy. However, many surgeons remain concerned with the adequacy of the exposure and are unwilling to use the FLI for anterior or superior tumors of the parotid gland because these tumors are closer to the superficially positioned facial nerve branch. To evaluate the changing trends in parotidectomy incisions for benign lesions at a single institute, and to compare the surgical outcomes between the modified Blair incision (BI) and FLI, and determine the adequacy and possible indications or limitations of the FLI, especially for tumors located in the anterior or superior parotid gland. Retrospective study analyzed 357 patients who had various benign parotid diseases and underwent parotidectomy at Severance Hospital between January 2005 and December 2009. Revisions or recurrences and histologically confirmed malignancies were excluded. Tumor location was divided into superficial and deep lobes. The superficial lobe was subdivided into anterior, superior, inferior, and middle portions. Patients' profiles, surgical outcomes, and cosmetic satisfaction score on a scale of 0 (extremely dissatisfied) to 10 (extremely satisfied) were compared. In all, 344 patients underwent BI or FLI. The FLI was performed increasingly each year. For anterior (n = 58) or superior tumors (n = 32), there was no significant difference between the type of incision and tumor size or complications. No facial nerve palsy occurred in either group. For deep-lobe tumors (n = 67), the mean tumor size was significantly larger in the BI group (p = 0.025). There was a significant difference between facial nerve palsy and tumor size (p < 0.001) but no significant difference between facial nerve palsy and tumor location (p = 0.145) or the type of incision (p = 0.530). The mean scar satisfaction score was significantly higher in the FLI group (p <0.001). There was a positive correlation between the scar and deep hollow satisfaction score (Pearson coefficient of correlation = 0.547; p < 0.001) The modified facelift incision is feasible for most benign parotid lesions regardless of tumor location, even for anterior or superior tumors. Using the modified facelift incision may be extended with a surgeon's accumulated experience, but for a large deep-lobe tumor, the modified Blair incision is still considered useful.

Introduction: Parotid tumors affect 1in100,000 people, representing 2-3%of tumors of the head and neck and 80% of salivary gland tumors. The literature estimates that approximately 80% of these tumors are benign, with pleomorphic adenoma being the most common followed by Warthin’s tumor. Among the malignant tumors mucoepidermoid carcinoma is the commonest, followed by adenoid cystic carcinoma. Material methods: It was a retrospective study done from January 2016 to December 2017 in the department of pathology Government Medical college Srinagar. Results: our study included 42 cases of parotid gland tumors. Out of 42 cases 25 were female and 17 were male patients. Thus the male to female ratio observed was 1:1.4. Pleomorphic adenoma (twenty cases) was the most frequent benign tumor followed by warthin’s tumor (five cases) while as mucoepidermoid carcinoma was the most frequently identified malignant tumor. Conclusion : pleomorphic adenoma is the most prevalent benign histological type while as mucoepidermoid carcinoma is commonest malignant tumor. Malignant tumors are more common in 5th decade while as benign lesions are commoner in 4th decade of life. Key words: pleomorphic adenoma , warthins tumor , mucoepidermoid carcinoma. Introduction: Tumours of salivary glands are rare constituting less than one percent of all tumors and 3% to 10% of the neoplasms of head and neck region (1). Parotid tumors affect 1in100,000 people, representing 2-3%of tumors of the head and neck and 80% of salivary gland tumors (2). The literature estimates that approximately 80% of these tumors are benign, with pleomorphic adenoma being the most common followed by Warthin’s tumor (3). The parotid gland has a superficial lobe, lateral to the facial nerve, that comprises 4/5 of the glandular parenchyma, and a smaller deep lobe. As 90% of the tumors are located in the superficial lobe and thus, do not affect the facial nerve hence superficial parotidectomy with facial nerve preservation is the most often indicated surgical procedure, (4). The most common manifestation of pleomorphic adenoma is the presence of a solitary, solid, firm, lobulated, painless, mobile nodular lesion with well-defined margins (5). Among the malignant tumors mucoepidermoid carcinoma is the commonest, followed by adenoid cystic carcinoma. The presence of pain, facial paralysis, rapidly growing tumor with ill-defined margins, and skin infiltration should raise the suspicion of malignancy (4). The first diagnostic imaging assessment for parotid tumors is usually ultrasonography (5). Fine-needle aspiration cytology (FNAC), whether or not guided by ultrasound, can be used as a complementary diagnostic test, especially when a non-characteristic manifestation of pleomorphic adenoma is suspected. The purpose of FNA is to differentiate benign from malignant lesions, as it usually does not establish the definitive histological diagnosis. However, histopathology remains the gold standard as it avoids diagnostic pitfalls of FNAC (3,4). Material methods: It was a single institute retrospective study done from January 2016 to December 2017 in the department of pathology Government Medical college Srinagar. Clinical data and gross features of tumours were recorded and tabulated. Haematoxylin and eosin (H&E) stained sections and corresponding paraffin tissue blocks were retrieved from the archives of the department and reviewed. The tumors were categorized according to the WHO classification. Results: During the period of two years a total of 69 salivary gland surgeries were performed, which included 42 (60.8%) parotidectomies. Thus, our study included only these 42 cases of parotid gland tumors. The demographic analysis is given in (Table.1). Out of 42 cases 25 were female and 17 were male patients. Thus the male to female ratio observed was 1:1.4. At presentation, the main finding was a tumor mass measuring >2cm in size in 73.8% of all cases reported in our study. Superficial lobe of parotid gland was the commonest site involved in Pleomorphic adenoma (twenty cases) (fig-1) was the most frequent benign tumor followed by warthin’s tumor (fig-2) (five cases) while as mucoepidermoid carcinoma (fig-3) was the most frequently identified malignant tumor (three cases) (Table.2). The most relevant clinical characteristics of the benign and malignant tumors are shown in Table 3.The ratio between men and women for malignant tumors was1:2, while for benign tumors it was 1:1.4. The mean age for the presentation of benign tumors was 46 years and for malignant tumors was 58 years.

Warthin's tumor is benign and exclusively involves the parotid gland but may, however, often show multifocal and/or bilateral growth. The aim of this study was to evaluate the surgical procedure for removal of this tumor. Sixty patients with Warthin's tumor in the parotid gland who presented at the Kansai Medical University Hospital from 1990 to 1999 were the subjects of the present study. The surgical procedures were as follows. We performed enucleation for tumors in the deep lobe. Tumors in the superficial lobe were resected with partial parotidectomy, and an enucleative procedure was also performed at the bottom of the tumor where the tumor capsule directly touched the facial nerve. No recurrence was observed in all sixty cases including cases of rupture of the capsule before or during surgery. Therefore, we recommend that enucleation is a useful choice as a surgical procedure for the removal of Warthin's tumor after accurate detection of the tumors using MRI. The overall incidences of temporary and permanent facial nerve palsy were 19.7% and 0%, respectively. The incidence of palsy increased after surgery for multiple tumors or deep lobe tumors. These findings indicate that more careful consideration for preservation of the facial nerve should be given in such cases and that simultaneous surgery for such tumors in the bilateral parotid glands should be avoided to prevent bilateral facial nerve palsy.

The location of Warthin tumor (WT) in the parotid gland impacts the surgical approach and may be indicative of the elusive origin of this intriguing entity. Location in the deep versus superficial lobe of the gland is not directly addressed when defining WT characteristics. Our observation, of rare occurrence of deep lobe WT, if at all, led to the current investigation. The study design is cohort study. This is a retrospective chart review of all patients undergoing parotidectomy for WT in two tertiary academic referral centers: the Sheba Medical Center (SMC), Israel, and the Christiana Care (CC), Newark, Delaware, USA. 122 consecutive adult patients underwent parotidectomy for WT (72 from SMC and 50 from CC). Seventy percent were males, with a mean age of 60.6years. Bilateral WT or multi-centric WT were found in 9.8 and 17.2% of the cases, respectively. In one case, the tumor was described as originating in the deep lobe. In all other cases, the tumor originated and was limited to the superficial lobe. 99.2% of WT originated in the superficial lobe, corresponding with the few reports directly addressing its location in the gland. The reason for the tumor to be limited almost uniformly to the superficial lobe is unknown, and could be related to the etiopathogenesis of this elusive entity. We suggest adding tumor location within the superficial lobe to the common characteristics of WT (male, smoking, and lower pole) that serve as "common criterion" while evaluating a parotid lesion.

BackgroundBilateral parotid gland tumors account for up to 3% of cases. In this group, the vast majority are Warthin’s tumors. However, bilateral presentations of other parotid gland tumor entities is also possible, an example of which is a basal cell adenoma (BCA). Bilateral BCA is extremely rare, which could cause misdiagnosing it as a Warthin tumor.Case presentationThe current study reports the unique case of a 48-year-old woman who presented with a 6-month history of slowly growing masses located bilaterally in the parotid region, surgically treated with 5-year follow-up (no recurrence, normal facial nerve function). Magnetic resonance imaging (MRI) revealed three lesions: two in the superficial and deep lobes of the right parotid gland, and one in the superficial lobe of the left parotid gland. A total parotidectomy with facial nerve preservation was performed on the right side, and superficial parotidectomy on the left side 6 months later. Histopathological examination confirmed that all three tumors were BCAs. Molecular analysis didn’t show any strong, potential of unknown clinical significance in the studied sample.ConclusionsMultifocal bilateral lesions of the parotid gland are usually Warthin tumors. Detailed preoperative diagnostics including MRI and histopathological examination is essential to avoid misdiagnosing BCA and Warthin tumors. To our best knowledge, no case of synchronous bilateral multifocal basal cell adenomas of the parotid gland has been reported in English literature so far.

IntroductionWarthin tumors are the second most common benign tumors of the parotid gland. We examined the clinical features of Warthin tumors in our hospital, and analyzed the consistency within the literatures. ObjectiveThe aim of this study is to analyze the clinical features of Warthin tumors in our 10-year experience of 118 Warthin tumors undergoing surgery at a single institute. MethodsFrom December 2006 to December 2016, 110 patients who underwent surgical treatment for Warthin tumors were identified based on their medical records. ResultsA total of 118 parotid gland operations were performed in 110 patients. Almost 90% of Warthin tumors were found in males, and average patient age was 66.1±6.1 years. The prevalence of smoking history was 89.1% (98/110). Eight patients (7.3%) had bilateral Warthin tumors. Seventy-seven lesions (65.3%) were located in the parotid tail portion, followed by 34 lesions in the superficial lobe (28.8%) and 7 lesions in the deep lobe (5.9%). ConclusionWe determined the appropriate extent of surgery depending on the fine needle aspiration cytology and tumor location by computed tomography scans. Partial facial dysfunction after the operation was detected in 12 cases, and facial nerve function recovered within 3 months. Only one patient experienced a recurrence, and was disease free after the re-operation. We suggest that our treatment algorithm, depending on the location of tumors and the result of fine needle aspiration cytology, can be useful to determine the appropriate extent of surgery for Warthin tumors.

To describe the clinicopathological presentation and treatment options in epithelial parotid tumours with emphasis on surgery. Descriptive study. ENT Departments of Pakistan Institute of Medical Sciences, Islamabad and Holy Family Hospital, Rawalpindi and Surgical Units at Rawalpindi General Hospital and DHQ Teaching Hospital, Rawalpindi, during a ten year period 1993-2003. Epithelial parotid tumours diagnosed and operated by an ENT surgeon and a general surgeon in 10 years during their posting in different teaching hospitals were included in the study. Clinical presentation, preoperative investigations, operative procedure, histopathology report, postoperative complications and further management were recorded. The data was collected and reviewed from the records of all the patients maintained by the authors. Fifty-two patients presented with parotid tumour. Average age was 38 years. Commonest presentation was a painless lump over the parotid region (85%), pain (15%), facial palsy, and enlarged neck nodes. Majority of tumours were benign, only two were recurrent. Parotid pleomorphic Adenoma (PPA) was the commonest benign tumour, others being Warthin's tumour and monomorphic adenoma. Adenoid cystic carcinoma was the commonest malignant tumour 29% followed by mucoepidermoid carcinoma. Others were carcinoma in PPA, squamous cell carcinoma, malignant mixed tumour, malignant lymphoepithelioma and undifferentiated carcinoma. Superficial parotidectomy (SP) was the commonest operation performed in 69%. Other procedures were total conservative parotidectomy in 11%, total radical surgery in 9% and enucleation in only one patient earliest in the series. Neck node dissection was done in 2 patients. Except for one child, rest of the 13 patients received postoperative radiotherapy and one patient of lymphoepithelioma received chemotherapy in addition. Commonest postoperative complication was temporary facial weakness in 35% (18/52). Permanent facial palsy occurred in 08 patients. Of these 07 had a malignant process and only one patient had excision biopsy. Benign and malignant epithelial parotid tumours can be diagnosed by their clinical presentation supplemented with FNAC. Superficial parotidectomy (SP) was the operation of choice. Facial nerve can be saved in total conservative parotidectomy for benign tumour in deep lobe and early malignant tumour. Radical parotidectomy followed by radiotherapy and in selected cases neck node dissection are the recommended procedures for advanced malignant parotid tumours.

Objective: This study presents the authors' experience with performing parotidectomy while using the microscope and its outcomes, particularly concerning the identification and preservation of the facial nerve and its branches. Study Design: Prospective study. Setting: Tertiary Care Hospital; in Rawalpindi. Period: January 2020 to December 2023. Methods: Enrolled 70 patients with parotid lesions treated patient selection was based on the presence of parotid lesions. Data was entered and analysed by using SPSS V.26. Results: The gender distribution was 29 males (41.43%) and 41 females (58.57%), with a mean age of 38.2 years. The majority of cases involved pleomorphic adenoma, constituting 74.28% (n=52) of the total cases. Other tumor types included Warthin tumor (5.71%, n=4), monomorphic adenoma (2.86%, n=2), Mucoepidermoid carcinoma (14.29%, n=10), and adenoid cystic carcinoma (2.86%, n=2). In terms of the type of surgery performed, 82.86% (n=58) of cases underwent superficial parotidectomy, while 17.14% (n=12) underwent total conservative parotidectomy. Regarding facial nerve outcomes, temporary facial nerve paralysis was observed in 8.57% (n=6) of cases, while permanent facial nerve palsy occurred in 2.86% (n=2) of cases. Conclusion: We have seen that a microscope is a very valuable assistant in the identification and preservation of the facial nerve. Thus, we can recommend its use during the procedure in order to prevent morbidity of the patient.

Objective To observe the therapeutic effect of individualized surgery and complications of pleomorphic adenoma of parotid (PAP). Methods Ninety patients with PAP in the 541th General Hospital of Yuncheng from January 2014 to January 2016 were enrolled. There were 69 cases with tumor maximum diameter less than 4 cm located in shallow lobe, undergoing parotid shallow lobe resection (shallow lobe group). There were 9 cases with tumor maximum diameter less than 4 cm located in deep lobe, undergoing parotid partial resection (partial group). There were 12 cases with tumor maximum diameter greater than or equaling to 4 cm, undergoing parotid total lobe (total lobe group). Histopathological diagnosis was performed on the patient after surgery, the pathological diagnosis results were recorded. The patients were followed up for 2 years after operation by telephone, the postoperative complications and recurrence in patients were observed. Results Among the 90 patients, the postoperative pathological examination found that the cell type, the classic type and the mucus type accounted for 37.78% (34 cases), 41.11% (37 cases) and 21.11% (19 cases), respectively; 71.11% (64 cases) patients had at least one of the four histological characteristics of pseudopodia, satellite lesions, capsular infiltration and incomplete capsular. None of the patients had permanent facial paralysis during the follow-up period. There were 5 cases (7.25%) with temporary facial paralysis in the shallow lobe group, however, there was no temporary facial paralysis in partial group or total lobe group. There were 17 cases (18.89%) with Fery’s syndrome, the incidence of Fery’s syndrome in the total lobe group was significantly higher than that in the shallow lobe group and partial group (P<0.05). There were 13 cases (14.44%) with earlobe numbness. No tumor recurrence was found during follow-up and no patient died. Conclusions PAP individualized surgery has good therapeutic effect, without recurrence after operation. Parotid shallow lobe resection and partial parotid resection can significantly reduce the incidence of postoperative Fery’s syndrome. Key words: Pleomorphic adenoma of parotid; Parotid shallow lobe resection; Partial parotid resection; Parotid total lobe resection; Complications

Background: Up to date, surgery is still the standard treatment for most parotid canccrs. However, factors associated with postparotidectomy facial nerve palsy are still poorly understood. Objective: To identify the potential risk factors for facial nerve palsy after parotidectomy in King AbdulAziz Medical City (KAMC) National Guard, Jeddah, Saudi Arabia between 2006 and 2013. Subjects and Methods: We retrospectively reviewed charts of patients who had parotid tumor and underwent parotidectomy at KAMC from 2006 to 2013. The facial nerve trunk was assessed prior to parotid gland resection. The gender of patients, side and location (deep or superficial) of tumors and postoperative facial nerve function, and size as well as pathologies of tumors were collected. Facial nerve function was graded using the standard House Brackmann grading system, and those with greater than a grade II facial palsy were placed in the facial palsy group.Results: The study group consisted of 50 patients with newly diagnosed primary parotid gland tumor. The most common histopathology was a nleomornhic adenoma (23 cases (46%Vi. followed by Warthin’s tumor in 8 cases (16%) and mucoepidermoid carcinoma in 4 cases (8%). Post parotidectomy facial nerve palsy was reported among 6 patients (12%) temporary grade II-III, each has one branch only whereas none has neither complete nor permanent palsy. Regarding the three most common histopathologica! types, the incidence rates of postoperative facial palsy w ere 2 of 23 patients (8.7%) with pleomorphic adenoma, none of 8 patients with warthin’s tumor and 2 of 4 patients (50%) with mucoepidermoid carcinoma. These differences were statistically significant, p=0,029.Conclusion: The difference between size, site and gender did not increase the incidence of post parotidectomy facial palsy. While histopathology increased the incidence of facial palsy postoperative with malignancy.

Malignant parotid tumor and facial palsy

We performed a systematic review and meta-analysis of deep lobe parotid tumors to evaluate their unique characteristics. PubMed/Medline, Embase, Web of Sciences, and Cochrane Library databases were queried for relevant literature. Studies were individually assessed by 2 independent reviewers. Risk of bias was assessed with the Cochrane bias tool, GRADE criteria, and MINORS criteria. Results were reported according to the PRISMA guidelines. Statistical analysis was performed by comparing rates of malignancy between deep and superficial lobe tumors. In total, 8 studies including 379 deep lobe parotid tumors met inclusion criteria. Mean age at diagnosis was 44.9 years. Computed tomography scan was the most common imaging modality. Preoperative diagnostic fine-needle aspiration was utilized in 39.4% of patients and demonstrated high sensitivity for malignant disease. The most common approach was subtotal parotidectomy with facial nerve preservation (58.9%). The rate of malignancy was 26.6%, which was significantly higher than that of the superficial lobe tumors in this study (risk ratio, 1.25; 95% CI, 1.01-1.56). The rate of temporary postoperative facial nerve weakness between deep and superficial lobe tumors was 32.5% and 11.7%, respectively. Deep lobe parotid tumors had a 26.6% rate of malignancy. On meta-analysis, deep lobe tumors appeared to have higher rates of malignancy than superficial lobe tumors. Surgical excision of deep lobe tumors showed increased rates of temporary facial nerve paresis as compared with superficial lobe tumors. Computed tomography scan was the most common imaging modality. There were limited data regarding the utility of fine-needle aspiration.

A rare case of bilobe parotid lipoma: Involving both superficial and deep lobe of parotid

In the first half of the 20th century, benign parotid neoplasms were enucleated, irradiated, or both. Complications were common, and recurrence rates for benign pleomorphic adenomas were high (20%-45%), probably because of spillage of tumor cells into the wound. A major advance occurred when Janes (1940) and Bailey (1941) described a supraneural approach to treatment of parotid neoplasms. The facial nerve runs through the parotid gland. It enters posteriorly as a main trunk, and branches within the gland. The cervical and marginal mandibular branches of the lower division are the lowest branches of the facial nerve in the neck. Although the branches share some redundancy, the nerve does not cross over itself. Dissection along one branch will not reveal a branch deeper to it. This branching pattern divides the gland into a deeper or medial portion, now often called the deep lobe, and a much larger, more superficial portion (superficial lobe). There is no true anatomic compartmental separation of the superficial and deep parotid lobes. Rather, the facial nerve constitutes the surgical division. The radiologic demarcation between deep and superficial lobes is an imaginary line from the stylomastoid foramen to the retromandibular vein or the lateral ascending ramus of the mandible. Inperformingasupraneural approach or superficial parotidectomy totreatabenignparotidneoplasm, instead of just shelling out the tumor, thesurgeonidentified the facialnerve andremovedthetumoralongwiththe rest of the parotid tissue lateral to the facial nerve. In this way, a cuff of normal tissue surrounded theneoplasm, and the capsule of the neoplasm was notviolated,minimizingspillageoftumor cells into the wound. In the ensuingyears,superficialparotidectomy wasfurtherrefined,resultinginrecurrence rates of 0% to 3%. A major morbidity of the superficial parotidectomy is postoperative facial nerve dysfunction. Intraoperative traction on the nerve and skeletonizationoften result in temporary paresis or paralysis. Functional sequelae are more common when the upper branches of the nerve are affected resulting in corneal exposure and the potential for keratitis and otherophthalmologicproblems.Since many pleomorphic adenomas occur in the tail of the parotid gland, inferior to the inferior division of the facial nerve, some surgeons began dissectingonly the trunkandinferiordivisionofthenerve,andremovingonly the parotid tissue inferior to the inferior division (subtotal superficial parotidectomy). As long as this preserved a cuff of normal tissue around the neoplasm, it was thought that no greater recurrence rate could be expected, and the upper division of the facial nerve would be protected.

Features of Parotid Gland Diseases and Surgical Results in Southern Taiwan