Dartmouth-Hitchcock Medical Center Research Articles

Palliation Specialist Urges End-of-Life Balancing Act

It is the practitioner's responsibility to make each dying patient's passage as peaceful and painless as possible, Dr. Ira Byock told his audience at AMDA Long-Term Care Medicine – 2013. The caregiver must balance a patient's personal preferences and beliefs, potential outcomes, financial considerations, and other issues at the end of life, said the author, professor of medicine, and director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. In a health care system that is profit-centered and disease-focused, Dr. Byock noted, care at the end of life often doesn't get the attention it deserves. “The fundamental nature of dying is only partly medical,” Dr. Byock observed. “Most fundamentally, it is personal and intensely so.” Care for people at the end of life calls for a sense of mutual responsibility and an understanding of community. Human caring includes the provision of shelter and hygiene, offering food and drink, assistance with elimination, giving company, and the alleviation of suffering, he said. The practitioner must accompany the patient on the journey to the end. This notion isn't just a “gimmick,” he said. “It's what every single human being wants.” The “best care possible” is that which is consistent with evidence-based practices, expert opinion, and consensus guidelines, he said. But Dr. Byock emphasized the importance of shared decision making. “Our patients are experts” on what matters to them as they approach death, and “we are experts in medicine.” Working together produces the best plan of care, but many misconceptions and disagreements about care may derail this conversation. For example, Dr. Byock pointed to a 2002 study that showed a variation in feeding tube use in dementia patients ranging from 4% in some states to as high as 45% in others (JAMA 2002;287:3211-12). Although there is “no evidence that people with advanced dementia or other serious illnesses are hungry as they die,” families often insist on feeding tubes, he said. “Neither the insertion of [percutaneous endoscopic gastrostomy] tubes nor timing of insertion affect survival in nursing home residents with advanced cognitive impairment.” One way to address family pressure to offer futile treatments, Dr. Byock said, is to encourage the use of Physician Orders for Life-Sustaining Treatment (POLST) forms. Also, “I want to encourage the use of hospice in nursing homes,” said Dr. Byock. Research has documented fewer hospitalizations among hospice patients in the last 6 months of life, superior pain assessment and treatment, fewer invasive treatments, less likelihood of having a feeding tube, and less use of restraints. However, he acknowledged “real challenges” to hospices taking charge of patients in nursing homes. Even clinical ethics can be a barrier to humane end-of-life care. Dr. Byock pointed to interventions such as mechanical ventilation, cardiopulmonary resuscitation, and medically administered nutrition and hydration that may be of no benefit to or even against the wish of a dying person. “I want us to think about the ethics of expansion. I want to expand the realm of imagination and think of what we might do” while still acting beneficently and in line with mutual trust between practitioner and patient. Dr. Byock talked about the importance of “loving care” at the end of life. He defined this as “interactions with a person which convey positive regard and are intended to alleviate distress, improve comfort, evoke pleasure, promote meaningful connections, or otherwise foster well-being.” Loving care might include massage or Reiki, storytelling and life review, music, prayer, meditation, companionship, eating, aesthetic grooming, play, ritual, and celebration. Practitioners can help dying patients take the opportunity to set their personal affairs in order, Dr. Byock said. This includes resolving previously strained relationships, reviewing one's life, considering meaning and purpose, and exploring spiritual and transcendent realms. This requires practitioners to make a commitment to honor the “inherent dignity of each and every human being.” Part of this involves letting people in nursing homes die in homelike environments. To allow nursing homes to be more community-like, overcoming the political and policy challenges facing health care and LTC will be more difficult. “The polarization in our country is getting in the way.” Policymakers and LTC leaders need to work on “common high ground” to ensure “adequate staffing and living wages for aide-level workers in long-term care,” Dr. Byock said. “We also need to enforce realistic training standards for physicians, nurses, and allied clinicians. And we need to eliminate the requirement to forgo disease treatments to receive hospice care.” Dr. Byock urged his audience to “take dying back.” He explained, “We need to provide leadership to help communities grow the rest of the way up. We can provide an example that the nation and the rest of civilization desperately needs.”

Mo1561 Comparative Effectiveness of Water Exchange vs Air Insuffaltion and Water Immersion vs Air Insufflation in Colonoscopy: a Meta-Analysis

Mo1561 Comparative Effectiveness of Water Exchange vs Air Insuffaltion and Water Immersion vs Air Insufflation in Colonoscopy: a Meta-Analysis

A Synopsis of Chromosomal Microarray Cases at Dartmouth‐Hitchcock Medical Center

BackgroundChromosomal microarrays (CMA) used to assess DNA copy number are currently considered first‐tier clinical diagnostic tests for postnatal evaluation of individuals with intellectual disability (ID), developmental delay (DD), autism spectrum disorders (ASD), and/or multiple congenital anomalies (MCA). Here, we provide a summary of the CMA cases performed at Dartmouth‐Hitchcock Medical Center during the first month that clinical CMA testing was offered.MethodsWe used the CytoScan®HD microarray containing 750,000 SNP probes and 1.9 million non‐polymorphic probes with an average intragenic spacing of 880 base pairs and 384 base pairs for 340 genes recommended by the International Standards for Cytogenomic Array (ISCA) consortium. Several databases of copy number variants were used during interpretation including ISCA, OMIM, DECIPHER and the Database of Genomic Variants (DGV).Results16 cases (9 females and 5 males) with an average age of ~7yrs were analyzed and reported. The clinical indication for testing in 14/16 cases (87.5%) was ID, DD or ASD. Clinically significant copy number variants were detected and reported in 3/16 cases, a diagnostic yield of 18.75%. Additionally, two variants of uncertain significance (VOUS) were also reported in two cases with unexplained developmental delay.ConclusionsDespite the small number of cases, our diagnostic yield matches the well‐established CMA yield (15–20%) for genetic testing of individuals with ID, DD, ASD or MCA. This further emphasizes the fact that CMA provides higher sensitivity compared to G‐banded karyotyping albeit with the slight disadvantage of increased VOUS detection.

From the Editorial Office

From the Editorial Office From the Editorial Office Thomas N. Ward MD, Thomas N. Ward MD Professor of Neurology Geisel School of Medicine at Dartmouth, Hanover, NHSearch for more papers by this author Thomas N. Ward MD, Thomas N. Ward MD Professor of Neurology Geisel School of Medicine at Dartmouth, Hanover, NHSearch for more papers by this author First published: 08 January 2013 https://doi.org/10.1111/head.12018 Conflicts of Interest: Dr. Ward declares no consulting, no paid research, and no speaker's bureau activity. He draws a salary from Dartmouth-Hitchcock Medical Center and has received a stipend from the American Headache Society as the most recent Editor-in-Chief of Headache Currents. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume53, Issue1January 2013Pages 1-1 RelatedInformation

Editorial introductions

Editorial introductions

Retrograde patient blood flow and rouleaux preventing red blood cell transfusion

TransfusionVolume 52, Issue 11 p. 2284-2284 TRANSFUSION MEDICINE ILLUSTRATED Retrograde patient blood flow and rouleaux preventing red blood cell transfusion Nancy M. Dunbar, Corresponding Author Nancy M. Dunbar From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Nancy M. Dunbar, MD, One Medical Center Drive, Lebanon, NH 03756-0001; e-mail: [email protected]. Search for more papers by this authorCynthia R. Marx-Wood, Cynthia R. Marx-Wood From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorKimberly J. Maynard, Kimberly J. Maynard From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorDavid P. Ng, David P. Ng From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorZbigniew M. Szczepiorkowski, Zbigniew M. Szczepiorkowski From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorLarry J. Dumont, Larry J. Dumont From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this author Nancy M. Dunbar, Corresponding Author Nancy M. Dunbar From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Nancy M. Dunbar, MD, One Medical Center Drive, Lebanon, NH 03756-0001; e-mail: [email protected]. Search for more papers by this authorCynthia R. Marx-Wood, Cynthia R. Marx-Wood From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorKimberly J. Maynard, Kimberly J. Maynard From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorDavid P. Ng, David P. Ng From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorZbigniew M. Szczepiorkowski, Zbigniew M. Szczepiorkowski From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this authorLarry J. Dumont, Larry J. Dumont From the Department of Pathology, the Department of Medicine, and the Center for Transfusion Medicine Research, Dartmouth-Hitchcock Medical Center; and Dartmouth Medical School, Lebanon, New Hampshire.Search for more papers by this author First published: 09 November 2012 https://doi.org/10.1111/j.1537-2995.2012.03601.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume52, Issue11November 2012Pages 2284-2284 RelatedInformation

American Pancreatic Association

American Pancreatic Association

The many facets of stress urinary incontinence.

The 2nd Annual Canadian Urology Forum (2012) focused on decisions and controversies in the management of two distinct clinical entities: stress urinary incontinence (SUI) in women; and lower urinary tract symptoms (LUTS) in men. Both sessions involved a distinguished panel of Canadian and international experts and combined the best evidence-based medicine with the considerable clinical experience of the faculty. The overall learning objectives of this session were to: Describe the pathophysiology of SUI in female patients; Determine appropriate approaches to treatment-related complications or failure in female patients who are experiencing SUI; and Measure patient outcomes and define successful treatment of SUI. To that end, faculty members were asked to cover six individual topics in SUI. Dr. John DeLancey, Norman F. Miller Professor of Gynecology and Professor of Urology at the University of Michigan Medical School, discussed the causes of SUI. Dr. Philippe Zimmern, Professor of Urology at the University of Texas Southwestern Medical Center at Dallas, provided an overview of what constitutes an appropriate workup for a woman with SUI. Dr. J. Christian Winters, Professor of Urology and Gynecology at the Louisiana State University Health Sciences Centre, reviewed the relevant evidence in presenting a rational approach to selecting a surgical intervention for women with SUI. Dr. Victor Nitti, Professor of Urology and Obstetrics and Gynecology and the Vice Chairman of the Department of Urology at New York University (NYU) Langone Medical Center, was tasked with reviewing the potential complications of midurethral slings and presenting options for managing these complications. Dr. E. Ann Gormley, Professor of Surgery (Urology) and the Program Director of the Urology Residency at Dartmouth–Hitchcock Medical Center in Lebanon, New Hampshire, discussed the appropriate management of women with a failed midurethral synthetic sling. Finally, Dr. Zimmern led a thought-provoking discussion of what constitutes treatment success for patients with SUI. The following pages feature brief summaries of each of the above topics. At the conclusion of these presentations, the faculty and participants interacted to discuss a case study detailing the appropriate management of a woman with complicated SUI. The highlights of this discussion are also captured in the following pages. The presentations and discussions on SUI at the 2012 Canadian Urology Forum were highly informative and clinically valuable to those in attendance. We hope that by providing the following summaries in this supplement format, these sessions can also provide valuable information to other health-care professionals in Canada and around the world.

Predictive Value of Current Imaging Modalities for the Detection of Urolithiasis During Pregnancy: a Multicenter, Longitudinal Study

We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis. A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated. A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively. The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention.

Point of View

From the Dartmouth-Hitchcock Medical Center, Lebanon, NH. Address correspondence and reprint requests to Jon D. Lurie, MD, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756; E-mail: [email protected] Acknowledgment date: November 8, 2011. Acceptance date: November 12, 2011. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

An Innovation Advisor Keeps Teamwork at the Heart of Hospital-Discharge Goals

D Stephen K. Liu wants to know whether a specialized team of elder-care providers can increase the likelihood that geriatric patients will be discharged to home rather than to a skilled nursing facility. Last December, Dr. Liu, medical director for the inpatient medicine unit at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was named as one of 73 “Innovation Advisors” in the newly created Center for Medicare & Medicaid Innovation (CMMI). The advisors, who were selected from among more than 900 applicants, are each working on a local quality improvement project. During his tenure as an innovation advisor, Dr. Liu will be analyzing whether the elder-care team he envisions can prevent deconditioning during patients’ hospital stays and improve communication among providers. In an interview, Dr. Liu discussed his quality improvement project and his role as an innovation advisor.

Computed tomography angiography: improving diagnostic yield and cost effectiveness in the initial evaluation of spontaneous nonsubarachnoid intracerebral hemorrhage

Computed tomography angiography (CTA) is increasingly used as a screening tool in the investigation of spontaneous intracerebral hemorrhage (ICH). However, CTA carries additional costs and risks, necessitating its judicious use. The authors hypothesized that subsets of patients with nontraumatic, nonsubarachnoid ICH are unlikely to benefit from CTA as part of the diagnostic workup and that particular patient risk factors may be used to increase the yield of CTA in the detection of vascular sources. The authors performed a retrospective analysis of 1376 patients admitted to Dartmouth-Hitchcock Medical Center with ICH over an 8-year period. Patients with subarachnoid hemorrhage, hemorrhagic conversion of ischemic infarcts, trauma, and known prior malignancy were excluded from the analysis, resulting in 257 patients for final analysis. Records were reviewed for medical risk factors, hemorrhage location, and correlation of CTA findings with final diagnosis. Multiple logistic regression analysis was used to investigate the combined effects of baseline variables of interest. Model selection was conducted using the stepwise method with p = 0.10 as the significance level for variable entry and p = 0.05 the significance level for variable retention. Computed tomography angiography studies detected vascular pathology in 34 patients (13.2%). Patient characteristics that were associated with a significantly higher likelihood of identifying a structural vascular lesion as the source of hemorrhage included patient age younger than 65 years (OR = 16.36, p = 0.0039), female sex (OR = 14.9, p = 0.0126), nonsmokers (OR = 103.8, p = 0.0008), patients with intraventricular hemorrhage (OR = 9.42, p = 0.0379), and patients without hypertension (OR = 515.78, p < 0.0001). Patients who were older than 65 years of age, with a history of hypertension, and hemorrhage located in the cerebellum or basal ganglia were never found to have an identified structural source of hemorrhage on CTA. Patient characteristics and risk factors are important considerations when ordering diagnostic tests in the workup of nonsubarachnoid, nontraumatic spontaneous ICH. Although CTA is an accurate diagnostic examination, it can usually be omitted in the workup of patients with the described characteristics. The use of this algorithm has the potential to increase the yield, and thus the safety and cost effectiveness, of this diagnostic tool.

Editorial introductions

Editorial introductions

Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent

Critically ill patients may require emergent intubations, and the use of some induction agents can lead to undesirable effects on hemodynamics. The use of "ketofol" (ketamine/propofol admixture) may allow for improved hemodynamic control. The primary aim of this study was to assess the hemodynamic effects of "ketofol" in a fixed-dose combination during induction of general anesthesia in a controlled environment. This was a randomized, double-blinded, placebo-controlled trial conducted at the Dartmouth Hitchcock Medical Center. American Society of Anesthesiology physical status I and II patients undergoing general anesthesia were randomly assigned to standardized induction with propofol alone or with "ketofol." Baseline noninvasive hemodynamic measurements were obtained and continuously monitored throughout the study period. Our hypothesis assumed that "ketofol" as an induction alternative would produce stable hemodynamics as referenced from baseline compared with propofol alone. The primary outcome was a systematic randomized assessment of changes in systolic blood pressure from baseline measurements for 30 minutes after induction. The primary comparisons were the frequency of a 20% change in systolic blood pressure at 5 minutes, 10 minutes, and 30 minutes after induction. Baseline patient demographics and intraoperative characteristics were equivalent in both groups. Propofol was more likely to generate a 20% reduction in systolic blood pressure from baseline at 5 minutes (48.8% vs. 12%, odds ratio: 6.87, 95% confidence interval: 2.07-26.15, p = < 0.001) and 10 minutes (67.4% vs. 39%, odds ratio: 3.24, 95% confidence interval: 1.21-8.75, p = < 0.01) as compared with "ketofol." This difference remained significant after adjustment for potentially confounding variables. "Ketofol" is associated with improved hemodynamic stability during the first 10 minutes after induction. Further study is needed to assess the efficacy of "ketofol" in critically ill patients and those with significant comorbidities. This combination has the potential to be used as an alternative agent for emergency induction during which time stable hemodynamics are desirable.

Optimum Timing for Planned Delivery of Uncomplicated Monochorionic and Dichorionic Twin Pregnancies

Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Financial Disclosure: The authors did not report any potential conflicts of interest.

Atlas of Ultrasound-guided Procedures in Interventional Pain Management

Atlas of Ultrasound-guided Procedures in Interventional Pain Management

Fast 3-D Tomographic Microwave Imaging for Breast Cancer Detection

Microwave breast imaging (using electromagnetic waves of frequencies around 1 GHz) has mostly remained at the research level for the past decade, gaining little clinical acceptance. The major hurdles limiting patient use are both at the hardware level (challenges in collecting accurate and noncorrupted data) and software level (often plagued by unrealistic reconstruction times in the tens of hours). In this paper we report improvements that address both issues. First, the hardware is able to measure signals down to levels compatible with sub-centimeter image resolution while keeping an exam time under 2 min. Second, the software overcomes the enormous time burden and produces similarly accurate images in less than 20 min. The combination of the new hardware and software allows us to produce and report here the first clinical 3-D microwave tomographic images of the breast. Two clinical examples are selected out of 400+ exams conducted at the Dartmouth Hitchcock Medical Center (Lebanon, NH). The first example demonstrates the potential usefulness of our system for breast cancer screening while the second example focuses on therapy monitoring.

Has there been any progress in improving the quality of hospitalised death? Replication of a US chart audit study

ObjectiveTo describe the experience of dying in a US tertiary academic medical centre and to compare this experience with a historical decedent sample.DesignA retrospective, observational, chart audit study of adults...

Medical Device Regulatory Landscape

The past 60 years have witnessed fundamental advances in our understanding and treatment of cardiovascular disease, prolonging and improving patients' lives. Central to these improvements has been the introduction of medical devices, including mechanical and biological heart valves, heart rhythm devices, and balloon angioplasty and stents. The introduction of these technologies has been dependent on an entrepreneurial medical device sector, coupled with an equally robust infrastructure to clinically develop and evaluate these new technologies. After approval and commercialization, continued study of device performance under “real world” conditions is crucial to ensure that the clinical potential is being realized. Central to a healthy medial device “ecosystem” is a robust regulatory system. Regulators must ensure that a device performs reliably and is adequately characterized, allowing physicians and patients to use it appropriately. Determining if/when a device is appropriate for approval is difficult and challenging and requires balancing its safety-efficacy profile. The technical sophistication required to make these determinations has grown as device complexity has grown. The stakes are very high, as illustrated by the recent Fidelis AICD lead recall, affecting 268 000 patients worldwide.1 These safety concerns must be balanced by the harm inflicted by withholding beneficial technology from patients. There is wide variation in how devices are regulated among countries with well-developed health care delivery systems, for example, the United States and Europe as well as Japan and Canada. The recent Food and Drug Administration (FDA) approval of the Sapien Transcatheter Heart Valve has brought these differences into sharp focus. In this commentary, we review the differences between the US and European Regulatory systems and how they have affected the investigational and approval process. ### Sapien Transcatheter Heart Valve: A Case Study On November 2, 2011, the Sapien Transcatheter Heart Valve (TAVR), manufactured by Edwards Lifesciences, was approved by the US FDA.2 The approval of the Sapien …

Parotidectomy: A 17-Year Institutional Experience at a Rural Academic Medical Center

We describe the parotidectomy experience at a single rural institution over 17 years. We retrieved the records of all patients who underwent parotidectomy for any nontrauma indication (current procedural terminology codes 42410, 42415, 42420, 42425, and 42426) from January 1990 to June 2007 at Dartmouth-Hitchcock Medical Center, a rural medical center that provides both primary and tertiary care to a local population of 14,000, with a catchment area of 600,000 people. Information was collected on initial patient presentation, use of fine-needle aspiration, extent of surgery, final pathologic diagnosis, and complications. We performed 341 parotidectomy procedures in 334 patients. The largest number of malignancies came from metastatic tumors; squamous cell carcinoma was the most common (37% of malignancies). The most common presenting complaint overall was a painless mass. The most common complication was facial weakness in 17% (57 of 341); 36 of the 57 cases of facial weakness (63%) were associated with surgery for malignancy. The most common benign tumor was pleomorphic adenoma (114 of 186; 61%). Mucoepidermoid carcinoma was the most common primary parotid malignancy (12%). In this 17-year rural case series of all parotidectomy procedures done for nontrauma indications, the largest number of malignancies came from metastatic tumors. Although facial nerve paralysis is not a common complication, it occurs most often when surgery is performed for either primary or metastatic malignancy. Surgeons will benefit from this information as they counsel patients who are considering parotidectomy.