Patient-reported quality-of-life outcomes following parotidectomy for benign parotid disease.

To document the outcome and impact on general and symptom-specific quality of life (QOL) after various types of parotid resection. General and symptom-specific QOL assessment at least 1 year after performed surgery. Retrospective data and outcome analysis of patients. Between 2004 and 2010, 353 parotid resections in 337 patients were conducted at the Department of Otorhinolaryngology, University Teaching Hospital, St. Mary's Hospital Gelsenkirchen, Gelsenkirchen, Germany. A total of 196 patients fit the inclusion criteria and were available for postoperative evaluation. The general QOL assessment was based on both the global health status and global QOL scales of the European Organisation for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire in 34 patients. Symptom-specific QOL was assessed with the Parotidectomy Outcome Inventory-8 (POI-8). In addition, aesthetic outcome was evaluated with an ordinal scale. Outcome of parotidectomies in benign disease has little impact on general QOL and global health status. However, hypoesthesia or dysesthesia, Frey's syndrome, and cosmetic discontent are quite common and may affect symptom-specific and general QOL. Correlation with extent of surgery and statistically significant differences of patient evaluation for aesthetic outcome, sensory impairment, and Frey's syndrome between various types of limited parotid surgery (enucleation, extracapsular dissection, partial superficial parotidectomy) and superficial parotidectomy could be shown. An adequate parotid resection technique must be chosen to achieve the least disturbing outcome. In addition, in our patient collective, there was no increased recurrence rate found after limited parotid resection for pleomorphic adenoma or cystadenolymphoma.

Superficial parotidectomy dramatically reduced the high rates of tumor recurrence that occurred with simple enucleation of parotid pleomorphic adenoma (PPA). However, there is not agreement in the medical literature confirming the exact margin of parotid tissue to be resected to avoid recurrence. Worldwide, SP and/or partial superficial parotidectomy (PSP) is commonly practiced for the treatment of PPA. In Europe and Asia, reports covering a spectrum from total parotidectomy (TP) to extracapsular dissection (ECD) are common. The outcomes (capsular exposure, tumor-facial nerve interface, capsular rupture, recurrence, facial nerve dysfunction, and Frey syndrome) from surgical treatment of mobile, superficial PPA smaller than 4 cm are not significantly altered by surgical approach (TP, PSP, or ECD). Retrospective series of pathological specimens were correlated with their clinical outcomes to compare TP, PSP, and ECD. Historical data review and meta-analysis were also performed. Matched pairs of 60 pathological specimens of PPA (20 cases treated by TP, PSP, and ECD, respectively) were compared for capsular exposure and the degree of cellularity of tumors. Statistical analysis of the respective rates of tumor-facial nerve interface, capsular rupture, recurrence, permanent and transient facial nerve dysfunction, and Frey syndrome was performed. Focal capsular exposure occurs in virtually all parotid surgery for PPA, regardless of the type of operation (margin). Dissecting PPA from the facial nerve led to a positive margin in 25% of cases. Capsular rupture does result in a significantly higher rate of recurrence and did not vary among surgical approaches (TP, PSP, and ECD). Tumor-facial nerve interface did not vary significantly by surgical approach. A less complete parotidectomy did not result in a higher rate of recurrence. Less parotid tissue sacrifice did not result in a lower rate of permanent facial nerve dysfunction, although it did result in significantly less transient facial nerve dysfunction and Frey syndrome. Hypocellular tumors did not have a higher incidence of capsular rupture or recurrence. Multicentric PPA was not identified in the clinically negative deep lobe for TP specimens. The most common cause of recurrence for PPA today is enucleation. The major outcomes of surgical treatment for small PPA (capsular exposure, tumor-facial nerve interface, capsular rupture, recurrence, and permanent facial nerve dysfunction) are not significantly altered by the amount of parotid tissue sacrifice (TP, PSP, or ECD). More complete parotidectomy results in higher rates of transient facial nerve dysfunction and Frey syndrome. Focal capsular exposure occurs in virtually all cases of parotid surgery for PPA. Dissecting PPA from the facial nerve results in cases with positive margins because of incomplete capsule or perforating pseudopodia. Few separations of pseudopodia from the main tumor occur with expertly performed contemporary parotid surgery because most of the PPA has a margin of normal parotid tissue. Minimal margin surgery in ECD is not recommended.

Iro andZenk1 are tobecommendedon their concise and thoroughdiscussionof the role of extracapsular dissection (ED) in the surgical management of benign parotid tumors. This discussion, aswell as a reviewof the literature, supports their hypothesis that “ED isa safeand effectivesurgical technique in the management of benign parotidneoplasms.”The true challenge is howbest to incorporate this information and surgical technique into the global management of parotid tumors. Several points require consideration: the correct definitionof theavailable andhistorical techniques for addressing parotid neoplasms, close analysis of the comparisons to date, a thorough understanding of the technique as well as evaluation of the relevant complication rates, and specific pitfalls associated with ED. Finally, as noted by all authors publishing on this procedure, significant expertise is required to successfully integrate ED into practice. Enucleation andnodulectomy should remainprocedures of historical note andnot be consideredwith currentmanagement techniques. ThedefinitionofED is very specificwith the goal of complete removal of the tumor with a 2to 3-mm cuff of normal parotid tissue, if possible, andno formal identificationof thenervebefore tumor removal. Superficial parotidectomy impliesdissectionof all facial nervebranches and the removal of theentire superficial lobe; partial parotidectomy (PP) implies the dissection of only nerve branches that is required to safely remove the tumor with a cuff of normal parotid tissue surrounding it. Historically, the pendulum swung drastically away from enucleation procedures because of the high recurrence rates toward the thorough superficial parotidectomy, which advocated wide margins around tumors, yet requiredextensive facialnervedissection. Inanappropriate fashion, thependulumhas returned centrallywithdemonstration that effective control ofbenignparotid tumors canbeachieved byPP, addressingonlybranchesof the facial nerve systemthat are in anatomical proximity to the tumor and leaving amuch smaller cuff of parotid tissue around the tumor.2 Extracapsular dissection represents the continuation of this principle by advocating theremovalof the tumorwithnervedissectiononly when required. The end points for surgical management of parotid tumors are straightforward: complete tumor removal in a fashion to prevent recurrence and limitation of any facial muscular dysfunction related to nerve dissection. Minor complications include Frey syndrome, periauricular numbness, and contour deformity. The significant surgical experiences with ED indicate the nearly equitable success of this procedure compared with superficial parotidectomy regarding recurrence and final facial nerve function. Extracapsular dissection demonstrates less transient nerve dysfunction in many series, which is understandable compared with the extensive facial nerve dissection that occurs with superficial parotidectomy.3 Directly comparing ED with appropriate PP procedures would be more informative and appropriate. Tumor recurrence rates and facial nerve functionwithED must also take into account that most ED series involved significant selectionbias,with smaller,mobile, and favorably selected tumors chosen to undergo ED and tumors that did not meet these criteria preoperatively or intraoperatively removed with superficial parotidectomy. These criteria clearly indicate that for ED to be successful, appropriate technique must be joined with excellent surgical decision making. The importance of capsular exposure in themanagement ofbenignparotid tumorscontinues tobeapointofdebate.Limited tumor exposure is commonwith all parotid surgeries and is not a significant risk factor for recurrence,4whereas formal disruption and spillage of the tumor presents a risk for recurrence. The risk of potential disruption or spillage could increase with greater direct exposure of the tumor capsule– parotid interfaceduringED.For this reason,EDtechniquesused in experienced centers attempt to leave a small cuff of parotid tissue on the tumor, allowing ED to limit the welldescribed pathologic features of incomplete capsule, tumor pseudopodia, and tumor satellites. The lower ratesofFrey syndromereportedwithEDareunderstandable, butmust be placed in the context of overall patient satisfaction and quality of life. The presence of gustatorysweatingonstarch iodineevaluationorbysolicitedpatient historymustbegradedby its effecton thepatient's life if avoidanceof this limitedcomplication is tobecomeapotentialdriver for a change in surgical technique that has afforded excellent results. Similarly, issues related to contour and cosmetic appearancemust beplaced in context. Again, themajor studies comparedEDand superficial parotidectomywhich, bydefinition, involves a greater resection of benign parotid tissue. Resultant contourdeformitieswouldbegreatly lessenedwithanappropriate PP combined with simple regional tissue mobilization techniques. Clinical experiencedemonstrates successful subjective results equivalent to those noted by Iro and Zenk1 in their experience. Potential pitfalls specifically related to ED exist. The success of ED is intricately related to technological support including appropriate preoperative imaging and facial nerve monitoring, which can be variable throughout practice centers. The authors1 note that revision parotidectomy after ED would be an easier procedure with fewer potential complications compared with other interventions. After ED, identification of the main trunk of the facial nerve system as well as previouslyuninvolvednervebrancheswouldbemorestraightforward.Yet, the facial nervebranches thatwere in closeproxRelated article page 768 Clinical Review& Education Clinical Challenges in Otolaryngology

The impact of the extent of parotid surgery on postoperative complications has long been considered a topic of controversy. The aim of the current network meta-analysis (NMA) is to answer the following questions: (1) Does the extent of surgical resection of benign parotid tumors increase the risk of postoperative complications? (2) What is the best surgical intervention for treatment of benign parotid tumors that can provide an acceptable balance between tumor recurrence rate and other postoperative complications? A comprehensive search on PubMed, Embase, Scopus, and Cochrane library was conducted to identify the eligible studies. The outcome was the incidence of tumor recurrence, facial nerve weakness (temporary [TFW] or permanent [PFP]), Frey's syndrome (FS), sialocele, and salivary fistula. The Bayesian network meta-analysis (NMA) accompanied by a random effect model and 95% credible intervals (CrI) were calculated using the GeMTC R package. Forty-four studies with a total of 7841 participants were included in the current NMA comparing five surgical interventions, namely enucleation, extracapsular dissection (ECD), partial superficial parotidectomy (PSP), superficial parotidectomy (SP), and total parotidectomy (TP). Enucleation showed the highest recurrence rate compared to ECD, SPS, SP, and TP. No statistical differences were observed concerning the recurrence rate when ECD, PSP, SP, and TP were compared together. There was an increased incidence of TFW and FS with the increase in the extent of parotid resection, while no significant difference was found when comparing enucleation with ECD and PSP. SP showed the highest incidence of PFP, and salivary fistula compared to ECD, PSP, and TP. The tumor recurrence rates in enucleation, ECD, PSP, SP, and TP were 14.3%, 3.6%, 3.7%, 2.8%, and 1.4%, respectively. The current NMA demonstrated that the risk of TFW and FS increases with the increase in the extent of parotid resection and that ECD and PSP can be considered the treatment of choice for benign parotid tumors, as both provide an acceptable balance between the incidence of tumor recurrence and facial nerve dysfunction.

Extracapsular dissection and limited parotidectomy

Preservation of Salivary Function Following Extracapsular Dissection for Tumors of the Parotid Gland

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).

Comparing capsule exposure using extracapsular dissection with partial superficial parotidectomy for pleomorphic adenoma

To determine the incidence of major and minor complications and their impact on patients' comfort after parotid surgery in benign disease. Retrospective. Four hundred ninety-two patients were included. Total parotidectomy (TP) was performed in 65.8%, superficial parotidectomy (SP) in 27.2%, and partial superficial parotidectomy (PSP) in 7.0%. Patients were interviewed using a self-designed questionnaire. Incidence of complications was evaluated depending on the extent of surgery and intensity of complaints. To ascertain the impact of morbidity on their daily lives, patients were asked to estimate it according to a visual analog scale. Frey's syndrome occurred in 63.4%, and temporary facial nerve palsy in 32.7% of all cases. Both rates were significantly reduced after PSP. Permanent facial nerve paresis was observed in 2.3% of the cases, but in no case after PSP. Perception of patients and their scores reflected these results. Scores regarding Frey's syndrome and facial nerve paresis showed a significant positive correlation with extent of surgery. The recurrence rate was 2.2%; no recurrences were noted after PSP. Scores of perceived general condition indicated an excellent state. The incidence of complications was reduced after PSP compared to SP or TP. Patient scores, which represent their perception of these complications, reflected these data and may be an additional instrument to measure outcome. These data suggest that less invasive operative techniques should be considered in case of a benign disease.

Objectives.Superficial benign parotid tumors are a common neoplasm of the salivary glands. Different surgical procedures have been applied for partial superficial parotidectomy (PSP) and extracapsular dissection (ECD), which are the two predominant surgical techniques. Our study aimed to evaluate PSP versus ECD for benign parotid tumors, in relation to post-operative complications and recurrence rates.Materials and Methods.266 patients who underwent parotidectomies of benign superficial parotid tumors were evaluated retrospectively. The first group (PSP group) was composed of 143 patients who underwent PSP, and the second group (ECD group) was composed of 123 patients who underwent ECD. Results.In the ECD group the rate of patients presenting with total postoperative permanent facial nerve paralysis, House-Brackmann grade III, was 0.8%, whereas in the PSP group it was 1.4%. Frey’s syndrome was only reported in the PSP group. Salivary fistula occurred in both groups at similar rates. Sensation dysfunction due to greater auricular nerve division occurred in 72% patients in the PSP group and 10.6% in the ECD group. No statistical difference regarding recurrence rates was found between the two groups.Conclusions.Both ECD and PSP procedures are safe surgical options for superficial parotidectomy in the treatment of benign tumors, with similar recurrence rates and post-surgical complications, apart from sensation abnormalities due to more extensive auricular nerve division.

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The extent of surgery for benign parotid pathology and its influence on complications: A prospective cohort analysis

Influence of parotidectomy extent on complications after benign parotid surgery.

To compare perioperative outcomes and surgical safety between extracapsular dissection (ECD) and partial superficial parotidectomy (PSP) for benign parotid tumors through a systematic review and meta-analysis. PubMed, Embase, and the Cochrane Library were searched for studies published up to March 2025. English-language studies that directly compared ECD and PSP in patients with benign parotid tumors were included. Data were extracted independently by two authors, and meta-analyses were conducted using a random-effects model. Outcomes included operative duration, drainage volume, hospital stay, tumor size, incidences of Frey syndrome, facial nerve (FN) injury (temporary and permanent), recurrence, as well as the rate of complete tumor excision. Fourteen studies met the inclusion criteria. Compared with PSP, ECD was associated with shorter operative duration (mean difference [MD], - 15.42min; 95% confidence interval [CI], - 23.47 to - 7.37), lower drainage volume (MD, - 31.32 mL; 95% CI, - 32.88 to - 29.76), shorter hospital stay (MD, - 0.54 days; 95% CI, - 0.78 to - 0.29), and reduced rates of both Frey syndrome (risk difference [RD], - 0.03; 95% CI, - 0.05 to - 0.00) and temporary FN injury (RD, - 0.12; 95% CI, - 0.20 to - 0.05). No significant differences were found in tumor size, recurrence, permanent FN injury, complete excision rate, or other complications. ECD and PSP demonstrate comparable surgical safety for benign parotid tumors. ECD offers certain perioperative advantages and may be a suitable option for appropriately selected patients. Further prospective studies are warranted to confirm these findings.