Parotidectomy Approach Research Articles

Gustatory otorrhoea: a rare case of congenital external ear salivary fistula

We present an extremely rare case of a 44-year-old woman with right gustatory otorrhoea and otalgia. The patient had been initially treated for otitis externa after Pseudomonas aeruginosa was grown from a microbiological swab. The otorrhoea fluid was collected and tested positive for amylase. Sialography and computed tomography imaging of the temporal bone confirmed a sialo-aural fistula from the right parotid gland to the bony external acoustic meatus. The defect was consistent with a patent foramen of Huschke. The fistula was identified surgically via a superficial parotidectomy approach, after contrast injection of Bonney's blue dye into the parotid duct, and then ligated and divided. The patient had immediate and sustained resolution of her otorrhoea. Sialo-aural fistulae are extremely rare, and usually arise as a complication of surgery or as an acquired disease process. To date, only four cases have been reported. This case demonstrates the use of sensitive investigation involving sialography and computed tomography, as well as successful surgical management, with complete resolution of symptoms.

副耳下腺から発生した多形腺腫例

The accessory parotid gland is a solitary salivary gland separate from the main parotid gland. Although it is recognized in 21-56% of individuals, the incidence of accessory parotid tumor is relatively rare. We report a 57-year-old male with pleomorphic adenoma arising from an accessory parotid gland. The patient had suffered from a gradually growing mass with no pain in his right cheek for six years. CT scans showed a well-circumscribed, 24×19-mm solid tumor lying on the masseter muscle. Fine needle aspiration revealed a cytological finding of pleomorphic adenoma. Considering the clinical course, radiological and cytological findings, pleomorphic adenoma of the accessory parotid gland was highly suspected. At surgery, a standard incision for parotid tumor was made and extended superiorly. Buccal branches of the facial nerve were detected at the anterior edge of the parotid gland. Total removal of the tumor with excision of the accessory parotid gland was performed. The pathological diagnosis was pleomorphic adenoma. Slight paresis of buccal branches resolved two months after surgery. No recurrence has occurred during 20-month follow-up. We recommend a standard parotidectomy approach that is safe and has cosmetic benefits for the surgical management of neoplasms arising from accessory parotid gland tissue.

An anatomical comparison of Blair and facelift incisions for parotid surgery

The rhytidectomy approach for parotidectomy allows the incision to be hidden, and post-operative scarring minimised. Furthermore, separate elevation of the Superficial Musculo-Aponeurotic System (SMAS) reduces the incidence of Frey's syndrome, and provides vascularized soft tissue for contour reconstruction. The technique has gained popularity particularly with plastic surgeons, but concerns persist that with this approach, particularly with lesions located anteriorly, access to the gland may be inadequate, and facial nerve identification may be compromised. We undertook an anatomical study to quantitatively compare the surgical access achieved using the facelift approach with the conventional Blair incision, by comparing the distances between the parotid edge and the retracted flaps. Despite reduced tissue elasticity due to formaldehyde fixation, it proved possible to demonstrate all regions of the parotid gland to the operating surgeon with either approach. There were no significant differences in the distance between the parotid edge and the retracted skin flaps (P > 0.1; paired t-test). The facelift approach provides at least equal access to all regions of the parotid gland when compared to a Blair's incision. It is a superior approach aesthetically and its more widespread use in parotid surgery is advocated.

Malignant eccrine poroma invading the parotid gland

Malignant eccrine poroma was first described by Pinkus and Mehregon in 1963. Because of the histologic characteristics of the tumor, these authors concluded that the tumor was likely of eccrine origin. Malignant eccrine poroma originates from the intraepidermal ductal portion of the eccrine gland. Like other tumors of skin adnexa, malignant eccrine poroma is a rare tumor. It mostly affects older persons. Clinical diagnosis is difficult, and lesions are often mistakenly identified as squamous cell carcinoma or pyogenic granuloma. We report a case of malignant eccrine poroma invading the parotid gland. A 65-year-old man presented with an ulcerated mass (2×3 cm) below the ear lobule of 3 months’ duration. The mass was fixed to the skin and underlying parotid gland. The lesion was treated using a superficial parotidectomy approach including the overlying skin. Simultaneous neck dissection was performed. The diagnosis was malignant eccrine poroma invading the parotid gland.

The Role of Imaging and Surgery in the Management of Vascular Tumors of the Masseter Muscle

Intramuscular vascular malformations are uncommon lesions in the head and neck that may mimic salivary gland disease. This study reports on the use of various imaging modalities and recommends a surgical approach in the management of vascular malformations of the masseter muscle. This is a retrospective study of 7 consecutive patients with vascular tumors of the masseter muscle treated in one unit between 1995 and 2004. The age, gender, signs and symptoms, imaging methods, and surgical outcome are reported. A previously unreported surgical approach is described. All patients had atypical swellings in and around the parotid region that were difficult to diagnose on plain radiography and computed tomography. Magnetic resonance imaging provides accurate three-dimensional images and provisional diagnosis of lesions within the masseter muscle. Six of the 7 patients underwent surgery by the recommended approach. No patients developed permanent facial weakness following modified parotidectomy. No recurrence of the vascular tumors occurred when the recommended approach is used. Magnetic resonance imaging remains the imaging modality of choice for the management of tumors of the masseter muscle. The extended parotidectomy approach gives good and safe surgical access in the management of these uncommon lesions.

Facial nerve schwannomas: A report of four cases and a review of the literature

Objective To evaluate both the surgical approaches and results of the facial nerve schwannoma cases as diagnosed in our clinic in line with the literature. Material and methods The files of 4 cases diagnosed in our clinic as facial nerve schwannoma between1996 to 2002 were reviewed retrospectively. All the cases were evaluated with detailed history; ear, nose, and throat examination; computed tomography; and/or magnetic resonance imaging. If required, electromyography and audiometric evaluations were made. Fine-needle aspiration cytology was also performed in appropriate cases. The surgical approach used was determined depending on the tumor location and its extent. Facial nerve reconstruction was accomplished if the integrity of the nerve could not be protected. Cases were followed up for facial nerve function, complications, and recurrence. Results The tumors occurred in the vertical (n = 2), internal auditory canal (n = 1), and the peripheric segment (n = 1) of the nerve. As symptoms, facial paralysis (n = 2), hearing loss (n = 3), tinnitus (n = 1), otorrhea (n = 2), parotid mass (n = 2), and external auditory canal mass (n = 1) were observed. Radiologic investigations provided important informations. However, fine-needle aspiration cytology did not contribute to a correct preoperative diagnosis. The superficial parotidectomy approach (n = 1), retrosigmoid approach (n = 1), and transmastoid-superficial parotidectomy combined approach (n = 2) were used. The integrity of the nerve could not be protected in 3 of the cases. After the reconstruction surgery, the facial nerve function was evaluated as House-Brackmann grade 3 for all 3 cases at the mean 38.6 months follow-up time. No tumors have recurred during follow-up. Conclusion Facial nerve schwannoma is a rare tumor. Through improved surgical and reconstruction techniques, postoperative morbidity is at acceptable levels. The rate of recurrence is low. It should be kept in mind for differential diagnosis of facial nerve paralysis. (Am J Otolaryngol 2004;25:426-431.)

An objective assessment of the advantages of retrograde parotidectomy

Objective This study was undertaken to determine whether the retrograde parotidectomy approach is more efficient than standard anterograde parotidectomy without compromise of surgical effectiveness. Methods A retrospective analysis of patients undergoing parotidectomy was conducted. Cases were divided into those undergoing retrograde facial nerve dissection and those undergoing standard anterograde facial nerve dissection. From the review of medical records, standard demographic information, surgical time, histopathology, estimated blood loss, and use of facial nerve monitoring were determined. Pathology was reviewed to determine the size of the overall resection specimen as well as the size of the lesion excised and margin status. Postoperative complications were also recorded. Statistical comparisons were conducted between these 2 approaches for these clinical variables such as surgical time, blood loss, tumor margin status and relative volume of tissue removed during parotidectomy. Results 45 patients undergoing parotidectomy met inclusion criteria. The average patient age was 50.8 years with a female preponderance (73%). There were 19 standard parotidectomies and 26 retrograde approaches. Compared to standard parotidectomy, retrograde parotidectomy consumed less operative time (3.2 versus 1.8 hours, respectively), decreased intraoperative blood loss (67.9 cc versus 40.3 cc, respectively), and resulted in less removal of normal parotid tissue (volume of normal parotid tissue removed in excess of tumor: 23.0 cc versus 6.0 cc, respectively). No significant difference in surgical margin status was noted between anterograde and retrograde parotidectomy ( P = 0.452). Conclusions In appropriately selected cases, compared with standard anterograde parotidectomy, retrograde parotidectomy is more efficient and spares normal parotid tissue without compromising surgical margins. Facial nerve monitoring provides a useful adjunct for retrograde dissection.

Child care safety checklist and home guide

The aim of the study was to evaluate the efficacy and preliminary outcomes of using a postauricular-groove approach without endoscopic assistance for the excision of parotid tumors.Patients who underwent parotidectomy using a postauricular-groove incision were selected for this study. For patients in which parotidectomy was difficult, namely, for tumors located in the deep lobe area, the parotid gland sternocleidomastoid space was fully utilized, and the tumor was resected from the posterior plane. A total of fifty-eight patients with parotid tumor were enrolled and divided into superior lobe group (n = 46) and deep lobe group (n = 12). The difference in operation time (94 vs 119 min) and postoperative drainage (20.18 vs 45.33 mL) was statistically significant between the tumors in the superficial and deep lobes. However, postoperative cosmetic VAS score was 10 (extremely satisfied) for all patients. The incidence of transient facial nerve paralysis was comparable (8.7% vs 16.7%), and all of them resolved spontaneously within 3 months. No recurrence of tumors was found in either group in the median follow-up interval of 26.45 months (range 22.2–35.3 months), which was comparable to the result using the conventional “S” approach.After making full use of the parotid gland sternocleidomastoid space, the postauricular-groove approach demonstrated satisfactory facial nerve protection, as well as easy maneuverability without the risk of surgical complications for tumors located in the deep lobe area. Importantly, the postauricular-groove approach showed excellent cosmetic outcomes for all patients and should be considered an alternative approach for parotidectomy of selected cases.

Conservative parotidectomy: a new surgical concept

Since Janes (1940) introduced the posterior approach for conservative parotidectomy, the method has been eleborated by many authors and various landmarks suggested for the approach to the trunk of the facial nerve. In all these methods the localisation of the nerve trunk proves either difficult or time-consuming. An operative concept is presented herewith which allows safe, quick and relatively simple localisation of the facial nerve. For this purpose only those landmarks are selected which are reliable and above all easy to identify. The main advantage is that position of the nerve trunk is remarkably constant, since cranial or caudal displacement with enlargement of the tumour is hardly possible--and this offers the opportunity to locate the nerve in the retromandibular fossa along an imaginary line joining the angle of the mouth to the mastoid process. The parotid plexus is dissected out completely including the cervical branch, which reinforces the function of the marginal mandibular branch through anastomotic connections and, together with the retained platysma plays an important role in the function of the mimetic muscles of the lower third of the face. The resulting operative depression is filled out by displacing the platysma posteriorly up to the Sterno-cleido-mastoid.