Parotid Gland Surgery Research Articles

Neuroprotective effects of TJ-23 (Tokishakuyakusan) on adult rat motoneurons following peripheral facial nerve axotomy

We investigated free radical scavenging activity and the possible neuroprotective effect of Tokishakuyakusan (TJ-23) on facial motor nucleus (FMN) motoneurons after peripheral axotomy. In 40 adult rats, the right facial nerve was transected at the level of the stylomastoid foramen. Following axotomy, the effects of TJ-23 on nitric oxide synthase were investigated using NADPH-d histochemistry. FMN motoneurons were counted bilaterally in sections stained with cresyl violet. Rats administered TJ-23 exhibited clear suppression of injury-induced neuronal NADPH-d expression in the ipsilateral FMN when compared to nontreated controls. The number of surviving motoneurons in the ipsilateral FMN was significantly greater among TJ-23-treated rats than nontreated controls on day 56 following axotomy. The present study demonstrates the neuroprotective effect of TJ-23 after peripheral facial nerve axotomy. Antioxidants may have therapeutic potential in traumatic facial nerve dysfunction resulting from head injury, ear surgery, and parotid gland surgery.

Localization of the Marginal Mandibular Branch of the Facial Nerve

The aim of this study was to observe the course of the marginal mandibular branch of the facial nerve (MMBFN) in relation to the inferior border of the mandible and parotid gland and its relevance to surgical procedures such as rhytidectomy and parotid gland surgery. In this study, 50 specimens were dissected. The relationships between the MMBFN and the inferior border of the mandible were recorded and analyzed. We found that posterior to the facial artery, the MMBFN ran above the inferior border of the mandible in 37 (74%) of the specimens. In 11 (22%) specimens, below the inferior border of the mandible it was divided into two branches at the crossing point with the facial artery. In 2 (4%) specimens the MMBFN divided into two branches at the point of emergence from the parotid gland. There were no statistical differences between the left and right sides, and both sexes. The MMBFN is one of the most vulnerable branches to surgical injury because of its location. For this reason, the surgeons who are willing to operate on this area, especially for the rhytidectomies, should have a true knowledge about the anatomy of this branch.

Prevention of Frey Syndrome in Parotid Gland Surgery

This study discusses the anatomy and surgical techniques for the prevention of Frey syndrome. By performing only a partial superficial parotidectomy, we probably preserve the connection between the auriculotemporal nerve and the facial nerve. By suturing the remainder of the parotid gland tissue and the superficial musculoaponeurotic system (SMAS) back to the sternocleidomastoid muscle, an interposition is made. Furthermore, by extending the incision not too far cranially, the auriculotemporal nerve cutaneous branch is spared. We also tried to preserve part of the great auricular nerve (GAN). Descriptive study. One main institute (a tertiary referral centre) and one affiliated secondary centre. Patients operated on for parotid gland tumours in our hospitals during the last 3 years underwent starch-iodine testing after at least 1 year of follow-up. The number of patients developing Frey syndrome. We hypothetically explored the importance of preserving both the auriculotemporal and the great auricular nerve. Eighty-one patients were operated on for a parotid gland tumour. Forty-five (56%) of these patients could be followed up for more than 1 year. Four patients had a positive starch-iodine test. Two of these underwent revision surgery and had symptoms already before our procedure. About half of the patients had a SMAS interposition performed. All four patients with Frey syndrome did not have a SMAS interposition. We advocate our technique in primary benign tumours. Further research to clarify the parasympathetic and sympathetic function of the great auricular nerve and the cutaneous branch of the auriculotemporal nerve is necessary.

How we do it: Changes in thyroid and salivary gland surgery since 1989: who's doing it and what are they doing?

Keypoints * The aim of this study was to identify changes in the provision of parotid, submandibular and thyroid gland surgery between surgical specialties since 1989, as well as changes in surgical practice. * Data from the Department of Health's Hospital Episode Statistics (HES) was extracted from 1989/1990 and 2003/2004 records by operation and surgical specialty in England. * The data reveals a considerable decline in the amount of parotid and submandibular surgery performed by General surgeons; with the majority of this surgery currently being performed by ENT surgeons, and to a lesser extent, Oral and Maxillo-Facial surgeons. * Thyroid surgery has undergone less radical change, with General surgeons continuing to perform the majority of cases; however, an increasing proportion is now provided by ENT surgeons. * There also seems to be changes in the types of thyroid operation being performed; with large increases in total thyroidectomy and reductions in subtotal thyroidectomies.

Anatomic landmarks of the buccal branches of the facial nerve

The aim of this study was to classify the buccal branches of the facial nerve in relation to the parotid duct and its relevance to surgical procedures such as rhytidectomy and parotid gland surgery. In this study, 30 cadaver heads (60 specimens) were dissected. The vertical and horizontal relationships between the buccal branches of the facial nerve and tragus, and parotid duct were recorded and analyzed. The buccal branches of the facial nerve were classified into four types: Type I: a single buccal branch of the facial nerve at the point of emergence from the parotid gland and inferior to the parotid duct. Type II: a single buccal branch of the facial nerve at the point of emergence from the parotid gland and superior to the parotid duct. Type III: buccal and other branches of the facial nerve formed a plexus. Type IV: two branches of buccal branch; one superior and one inferior to the duct at the point of emergence from the parotid gland. The buccal branches of the facial nerve are very vulnerable to surgical injury because of its location in the midface. For this reason, the surgeons who are willing to operate on this area should have a true knowledge about the anatomy of these branches.

The use of botulinum toxins to treat hyperhidrosis and gustatory sweating syndrome

Hyperhidrosis is a chronic condition characterized by excessive sweating. Recent studies report that it affects approximately 2.8% of the population and typically begins during adolescence. Gustatory sweating usually occurs after parotid gland injury or surgery, and both disorders can be debilitating for those who are affected. Both diseases respond very well to botulinum toxin therapy and this article will review the use of botulinum toxins, including the serotypes used, dosing, and complications.

Morbidity of parotid gland surgery: results 1 year post-operative

Patients operated on for parotid gland tumours were evaluated prospectively to study morbidity after this procedure. Nowadays, major complications such as recurrence of tumour and permanent facial nerve paresis are rare after primary surgery. Therefore, this study especially takes minor complications such as Frey's syndrome and sensory deficits into account. The study documents morbidity in 45 patients who completed a 1 year follow-up. Among those with primary benign tumours, we found no recurrences and no permanent paresis, nor did starch-iodine testing reveal any cases of Frey's syndrome. However, two patients who had previously been operated on multiple times did test positive for Frey's syndrome, as did two others after surgery for malignancy. Furthermore, we found that patients whose posterior branch of the great auricular nerve was sacrificed had a larger area of sensory deficit than those whose nerve was preserved. We conclude that the morbidity of parotid gland surgery can be reduced further by giving minor complications more attention.

Electromyography Monitoring of Patients With Salivary Gland Diseases

To provide a description of surface electromyography (sEMG) of spontaneous saliva swallowing (SSS) and monitoring of swallow rate in patients with salivary gland diseases. Numbers of SSS obtained during 2 hours of sEMG monitoring were compared with sialometry data for healthy volunteers (n = 100), patients with Sjögren syndrome (n = 10), and patients after parotid gland (n = 15) and submandibular gland (n = 16) surgery. Normative: 1 SSS every 2 minutes and 15 seconds; Sjögren: 1 SSS every 13 minutes (P < 0.001); parotid gland surgery: 1 SSS every 3 minutes and 24 seconds (P = 0.26); submandibular gland surgery: 1 SSS every 5 minutes and 04 seconds (P < 0.05). Sjögren patients and patients after submandibular surgery had hyposalivation correlated with less SSS. The established normal rate of SSS makes this modality applicable for evaluating salivary flow for potentially identifying and ruling out abnormalities. Parotid gland surgery does not significantly affect salivary flow rate. Sialometry combined with sEMG monitoring give a clinician more reliable data to evaluate salivary gland disorders than sialometry alone.

The Use of the Ligasure Vessel Sealing System in Parotid Gland Surgery

To evaluate the role of the Ligasuretrade mark Vessel Sealing System (LVSS; Valleylab, Boulder, CO) in parotid surgery. A prospective study was conducted on 12 consecutive patients undergoing superficial parotidectomy, performed by using the LVSS device as the primary means of ligation. Inclusion criteria included parotid mass with no preoperative suspicion of malignancy, and no extension to the deep lobe of the parotid gland. Efficacy of hemostasis, cut-closure time, and postoperative complications were assessed. Results were compared with a historical control group, including cases on which the LVSS was not available. LVSS proved effective in providing ligation and hemostasis. There was a mean time gain of 52 minutes, compared with our historical control group. No postoperative bleeding, seroma, salivary fistula, or Frey syndrome were observed. One case of transient facial weakness occurred, which was completely resolved within 6 months. LVSS is a safe device for parotid gland surgery, providing sufficient hemostasis and reducing operative time. B-2.

Preliminary Experience with Botulinum Toxin Type A Intracutaneous Injection for Frey's Syndrome

Gustatory sweating, the main symptom of Frey's syndrome, usually occurs after parotid gland surgery. Numerous medical and surgical treatments have been proposed to treat this condition, but there are various drawbacks. Botulinum toxin type A intracutaneous injection is a relatively new treatment modality; its use has never been reported in Taiwan. Here, we present our preliminary experience with this technique and review the literature. Between March 2002 and June 2005, 10 consecutive patients with severe gustatory sweating were managed with intracutaneous injection of botulinum toxin type A for a total of 16 times. The affected skin was visualized by Minor's starch-iodine test and then recorded. The interinjection distance was 1 cm and a mean dose of 46.4 U (at a concentration of 2.5 U/0.1 mL) was used. In all 10 cases, gustatory sweating improved within 2 days after injection, with no side effects. Patients in whom the first 13 injections were performed experienced recurrence of gustatory sweating. Mean duration of effectiveness was 9.3 months; the shortest duration of effectiveness was 2 months and the longest was 28 months. One patient also had gustatory flushing, but this symptom did not improve even after 3 treatments. Intracutaneous injection of botulinum toxin type A is a highly reliable, effective, safe, and minimally invasive treatment for gustatory sweating. Some patients had long-lasting therapeutic results. We recommend it as a valuable treatment option for severe cases of gustatory sweating. However, in our experience, it had no effect on facial skin flushing. Therefore, in addition to acetylcholine, there might be other neurotransmitters that are responsible for skin vasodilatation.

Patterns of Use of Facial Nerve Monitoring During Parotid Gland Surgery

To determine current patterns of use of facial nerve monitoring during parotid gland surgery by otolaryngologists in the United States. A questionnaire encompassing surgeon training background, practice setting, patterns of facial nerve monitor usage during parotid gland surgery, and history of permanent facial nerve injury or legal action resulting from parotid surgery was mailed to 3139 otolaryngologists in the United States. Associations between facial nerve monitor usage and dependent variables were examined by using the chi(2) test. Magnitudes of the associations were determined from odds ratios calculated using logistic regression. A 49.3% questionnaire response rate was achieved. Sixty percent of respondents who perform parotidectomy employed facial nerve monitoring some or all of the time. Respondents were 5.6 times more likely to use the monitor in practice if they used it in training and 79% more likely to use it if they performed more than 10 parotidectomies per year. Respondents were 35% less likely to have a history of inadvertent nerve injury if they performed more than 10 parotidectomies per year. Surgeons who employed monitoring in their practice were 20.8% less likely to have a history of a parotid surgery-associated lawsuit. Additional information regarding surgeon demographics, types of nerve monitors used, and reasons for and against monitor usage are discussed. Permanent facial nerve paralysis after parotidectomy occurs in 0-7% of cases. Currently, a majority of otolaryngologists in the United States are employing facial nerve monitoring during parotid surgery some or all of the time, even though no studies to date have demonstrated improved outcomes with its use. Physician training background and surgery caseload were significant factors influencing usage of facial nerve monitoring in this study.

Usefulness of the LigaSure Vessel Sealing System During Superficial Lobectomy of the Parotid Gland

To evaluate the usefulness of the LigaSure Precise instrument in superficial lobectomy of the parotid gland. Prospective study of the surgical procedures in the LigaSure Vessel Sealing System and comparison with a conventionally treated control group. Secondary care academic referral center. Patients Thirty-five patients with a parotid gland benign tumor were randomly allocated to 2 superficial lobe parotidectomy groups: 17 using the LigaSure procedure (group A) and 18 using the conventional method (group B). During the past few years, different methods of achieving hemostasis in parotid gland surgery have been tested as means of decreasing operative time and facial nerve injuries by controlling bleeding. With the whole LigaSure Vessel Sealing System, we experienced the usefulness of the LigaSure Precise instrument in superficial lobectomy of the parotid gland. No statistically significant differences were noted between the 2 groups in mean age, tumor diameter, length of hospital stay, time to return to work, or number of adverse events during or after surgery. Operative time was significantly shorter in group A than in group B (P < .001). Total operative time for conservative partial parotidectomy with traditional excision ranged from 115 to 235 minutes (mean, 155.8 minutes). Using the LigaSure system, the mean operative time was 136.4 minutes. Salivary fistulas were more common in group A (3 of 17 patients), with no cases in group B. The LigaSure method is comparable with but not superior to the conventional method. The main advantages of the LigaSure system are its "sutureless technique" and operative time savings; however, the cost is considerably higher.

The Advantages of Microsurgical Dissection Applied to Parotidectomy for Benign Lesions

Preservation of facial nerve function is a fundamental principle of parotid gland surgery. Microsurgical dissection has been applied to the resection of benign parotid tumors in 21 cases. One of them was AVM and the other cases were pleomorphic adenoma. The results showed that only 1 (6.25%) had minimal facial weakness in the group of superficial parotidectomy and 2 (40%) in the group of parotidectomy. In this study, only 3 patients (14.3%) encountered temporary weakness of the facial nerve and no permanent paralysis or weakness noted. The asymmetry disappeared at 3 months of follow-up. The average operation time was 3 hours for superficial parotidectomy and 3.5 hours for total parotidectomy. Dissection under microscope for parotidectomy has the following advantages: (1) Meticulous identification and preservation of all nerve branches. (2) Preservation of blood supply to the nerve branches, even in total parotidectomy. (3) Avoidance of inadvertent cauterization to minor branches, especially in recurrent cases. (4) Minimal traction. (5) Achieving same good results with basic microsurgical technique and experience. Dissection under microscope has the disadvantages of longer operation time. We propose a meticulous method for parotidectomy of benign lesions, which can reduce the incidence of temporary facial paresis and resultant psychological impact, especially in large tumors or recurrent cases.

Patterns of use of facial nerve monitoring during parotid gland surgery

Objectives: The purpose of this study was to determine current patterns of use of facial nerve monitoring during parotid gland surgery by otolaryngologists in the United States. Methods: A questionnaire encompassing training background, practice setting, patterns of facial nerve monitor usage during parotid surgery, and history of permanent facial nerve injury or legal action resulting from parotid surgery was mailed to 3139 otolaryngologists in the United States. Associations between monitor usage and dependent variables were examined using X2 tests, and magnitudes of associations were determined with odds ratios calculated using logistic regression. Results: A 49.3% questionnaire response rate was achieved. Sixty percent of respondents who perform parotidectomy used facial nerve monitoring some or all of the time. Respondents were 5.6% more likely to use the monitor in practice if they used it in training and 79% more likely to use it if they performed over 10 parotidectomies per year. Respondents were 35% less likely to have a history of inadvertant nerve injury if they did more than 10 parotidectomies per year. Surgeons who used monitoring in their practice were 20.8% less likely to have a history of parotid surgery-associated lawsuit. Additional information regarding demographics, type of nerve monitors used, and reasons for and against monitor usage are discussed. Conclusions: Permanent facial nerve paralysis following parotidectomy occurs in 0%-7% of cases. Consequently, a majority of otolaryngologists are turning to facial nerve monitoring during parotid surgery to reduce this complication rate even further. Physician training and surgery caseload are significant factors influencing usage of facial nerve monitoring.

Parotid gland surgery: 4-year review of 118 cases in an Asian population.

To determine the presentation and management of parotid lesions requiring excision in a largely Chinese Asian population. Retrospective study of 118 consecutive parotidectomies. Thirty-seven percent were Warthin's tumor (WT), 33% pleomorphic adenoma (PA), 21% other benign disease (OBD), and 9% malignant tumor (MT). Mean age was significantly different between benign (51 years) and malignant (40 years) lesions. MT decreased above 50 years, but increased five times with pain and two times with a noninferior pole lesion. Sensitivity of fine-needle aspiration (FNA) for differentiating benign from MT = 78%, for WT =5 8%, for PA =82%, for OBD = 28%, and for MT = 38%. CT scans did not alter WT management. Facial nerve (FN) paresis was not associated with histology, tumor size, site, or parotidectomy type. This is the first report documenting that most benign parotid tumors are WT and not PA. MT risk is greater in those less than 50 with pain and a noninferior pole lesion. Cystic lesions such as WT require great care in the evaluation of FNA findings.

Temporoparietal fascia flaps and superficial musculoaponeurotic system plication in parotid surgery reduces Frey's syndrome

Purpose: The purpose of this retrospective study was to evaluate the incidence of Frey's syndrome after parotid gland surgery with elevation of a skin flap versus the interposition of musculoaponeurotic tissue between the skin and the facial nerve. Materials and Methods: The standard skin flap was used in 122 patients (1981 to 1989), whereas interposition of temporoparietal galea or superficial musculoaponeurotic system was performed in 146 consecutive patients (1989 to 1998). Results: The incidence of Frey's syndrome was reduced from 33% to 4% with the use of a musculoaponeurotic layer, and the mean duration of postoperative facial nerve paresis decreased from 3 months to 6 weeks. Conclusions: Consideration should be given to the use of an interpositional layer of tissue between the facial nerve and the skin flap to reduce the incidence of Frey's syndrome after parotid gland surgery. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:1284-1297, 2002

Intravital staining with methylene blue as an aid to facial nerve identification in parotid gland surgery

Superficial or total parotidectomy is always a challenge to the surgeon because of the great amount of attention that is directed toward identifying the facial nerve. The success of the surgery depends on complete resection of the tumor while also preserving the facial nerve. Currently, the accepted technique for identifying the main trunk of the facial nerve as it leaves the stylomastoid foramen relies on visualizing anatomical landmarks such as the mastoid process and the insertion of the sternocleidomastoid muscle, the posterior belly of the digastric, and the pointer cartilage of the ear. Yet, identification of the nerve can be difficult when individual regional anatomic variations are present or when tumors, particularly large ones, displace the gland and alter the local anatomic landmarks. When this situation is present, the surgeon will need to use other techniques to safely identify the nerve. Detection of muscle movement or muscle electrical activity detection is normally used for confirmation of facial nerve identification, thus reducing the risk for iatrogenic injury and assessing neural integrity following dissection.1 Another identification method is preoperative intravital staining of the parotid gland with methylene blue (MB). Although MB staining is not designed to be used as a sole technique, it can be combined with other techniques such as identification of the anatomic landmarks and use of nerve detection devices. MB staining is easy and not time consuming. It is an indirect facial nerve identification technique, because there is no nerve handling, thus decreasing iatrogenic nerve impairment. After injection of the parotid gland with MB dye, fine white nerve fibers can be observed (Figs 1, 2). Tumors in the parotid gland are also easily seen because they are not stained and will be visible in the surgical field.

Landmarks for parotid gland surgery.

Many surgical landmarks have been suggested to help the surgeon identify the facial nerve when performing parotid gland surgery. There is no conclusive evidence that any one landmark is better than the rest. In this study distances from the most frequently used surgical landmarks to the main trunk of the facial nerve were measured in 30 halves of cadaver heads. Two ENT surgeons assessed the best landmark in each case. The tympanomastoid suture was nearest to the main trunk and was therefore considered the most reliable landmark. Its average distance to the main trunk of the facial nerve was 2.7 mm. This result was consistent with the subjective best score given by two ENT surgeons.

Parotid gland malignant melanomas.

Malignant melanomas are relatively unusual tumors in the parotid gland. The majority of previously reported cases appear to represent metastatic lesions, often from cutaneous head and neck primaries. Retrospective clinicopathologic review of 12 cases of malignant melanoma involving the parotid gland encountered between 1980 and October 1999 at a tertiary referral center. Patients consisted of 9 men and 3 women ranging in age from 30 to 84 years (median, 66 years). Eleven of 12 patients presented with a neck mass or nodule. In 9 of 12 patients, a cutaneous or conjunctival primary was noted in the head region. In 2 patients, a cutaneous melanoma and the parotid gland melanoma were diagnosed at the same time. In 1 patient, melanoma was initially diagnosed in the parotid gland, and a definite primary was not uncovered. All patients underwent excision of the parotid melanoma, which was accompanied by a lymph node biopsy or dissection in 10 out of 11 patients. Four patients received adjuvant radiotherapy, and 3 patients received adjuvant chemotherapy. Four of 11 patients had ipsilateral cervical lymph node metastasis at the time of parotid tumor resection, and 5 patients had involvement of intraparotid lymph nodes by metastatic melanoma. Tumors ranged in size from 0.3 to 2.5 cm in greatest dimension. Multiple parotid nodules were noted in 4 patients. All tumors were characterized by a diffuse proliferation of cells with abundant eosinophilic cytoplasm and prominent nucleoli. Four tumors demonstrated focal spindle cell regions. Intravascular and/or lymphatic involvement by tumor within the parotid gland was noted in 3 lesions. At last known follow-up, 6 patients had died with tumor at a median follow-up period of 11 months after parotid gland surgery. Four patients were alive with evidence of tumor at follow-up intervals of 4, 17, 21, and 113 months after parotid gland surgery. Two patients were alive with no evidence of residual tumor at 20 and 148 months of follow-up. The majority of melanomas involving the parotid gland appeared to be associated with lymph node metastasis in and around the gland from a cutaneous primary in the head region. Prognosis is generally poor, although rare patients may survive a long period of time following surgery.

Water-jet dissection in parotid surgery--initial clinical results

The most frequent complication following parotidectomies is postoperative facial nerve dysfunction. In animal experiment we successfully studied the technique of water-jet-dissection for safe and functional preservation in facial nerve dissection in parotid gland surgery. The aim of the present study was to evaluate our animal experiments clinically. Until November '99 ten patients with benign parotid gland tumors (4 female, 6 male, age 32-77 years) underwent lateral or latero-segmental parotidectomies using water-jet-dissection ("Hydro-Jet", Andreas Pein Medizintechnik GmbH, Schwerin, Germany). All operations were performed under permanent intraoperative facial nerve monitoring ("Neurosign 100", Fa. Inomed, Tenningen, Germany). The postoperative facial nerve function was measured daily by the House-Brackmann and Stennert-Paresis-Index for at least one week. A quick parotid gland and safe facial nerve dissection could be performed in all operations using the 120 microns-nozzle with effective working pressures from 30-50 bar. In addition strong connective tissue fibers were transected with scissors. Intraoperative facial nerve lesions did not occur and cardiopulmonary complications due to eventual cutting-fluid-resorption were not seen. After surgery all patients had a normal facial nerve function. The results of our studies showed that the technique of water-jet-dissection provides safe facial nerve dissection and preservation during parotid gland surgery. The tissue selective cutting qualities of the new surgical method are an excellent alternative compared to standard dissection methods in parotid surgery.