Permanent Facial Dysfunction Research Articles

The significance of the margin in parotid surgery for pleomorphic adenoma.

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.

Pleomorphic adenoma of the parotid gland: is long-term follow-up needed?

Introduction: Pleomorphic adenoma is a slow-growing benign salivary tumour most commonly arising in the parotid gland. Macroscopically it has a surrounding capsule from which it can be enucleated—often the treatment used in the past. These tumours do not have a true capsule but can press surrounding normal salivary gland, frequently having finger-like extensions into the normal tissues. Recurrence, or more accurately residual disease, is thought to be due to these small islands of tumour which can be left behind at surgery, in particular enucleation which is associated with high recurrence rate. The current, most common practice is the excision of these tumours through superficial parotidectomy and postoperative follow-up. However, is long-term follow-up necessary and does it reduce the morbidity from tumour recurrence? Methods: We reviewed the charts of 182 patients who underwent parotid surgery operated upon by a single surgeon (RKM) between 1973 and 1999. We included only 58 cases of pleomorphic adenomas removed by superficial parotidectomy. We excluded cases that had follow-up of less than 12 months and cases which had previous surgery elsewhere. Adequate tumour excision and the integrity of the capsule were ascertained intra-operatively, and this was confirmed by postoperative histology. Results: In our study we had 34 females, mean age of 58, and 24 males, mean age of 50. The average follow-up was 6 years with a range of 1–23 years. We had no permanent facial nerve dysfunction, and we recorded only one recurrence (1.7%). Conclusion: Provided adequate excision of the tumour with intact capsule and histological confirmation are achieved, long-term follow-up is unnecessary and can be replaced by patient education and self-examination.

Facial nerve function after partial superficial parotidectomy: An 11-year review (1987-1997)

Permanent facial nerve dysfunction is a potential complication of every parotid surgery. Partial superficial parotidectomy, a conservative resectioning that requires neither dissection of the full facial nerve nor excision of the superficial lobe, produces lower rates of facial nerve dysfunction and soft tissue deformity than the traditional method. This report describes a single surgeon’s experience with partial superficial parotidectomy from 1987 to 1997. Fifty-nine patients with mobile, benign, and low-grade malignant tumors, limited to the superficial lobe, underwent partial superficial parotidectomy with selective nerve dissection. Adequate margins were obtained, based on the premise that the tumor-to-nerve margin is often the true one. No patients had permanent nerve paralysis or paresis, and only 10 incurred transient facial nerve paresis. Age, histology, and sex were not significant factors in postoperative facial nerve function. No patients had recurrences. (Otolaryngol Head Neck Surg 1999;121:210-3.)

Facial nerve monitoring in skull base surgery

The purpose of this work was to compare pre- and post-operative facial nerve function between unmonitored and monitored cases of skull base lesions. The study involved 32 patients suffering from lateral skull base tumours (10 unmonitored and 22 monitored). Facial nerve function was monitored intraoperatively by an acoustic facial electromyographic system (NIM-2). Post-operative facial function was graded according to the House-Brackmann scale. In the group of monitored cases, facial nerve function was normal (Grade 1 or 2) in 79 per cent of the patients, while the unmonitored patients showed normal function in only 50 per cent of the cases. These results confirm previous observations that audible evoked electromyographic monitoring significantly reduces permanent facial nerve dysfunction.

Surgical management of chronic parotitis.

A series of 17 consecutive parotidectomies for chronic sialoadenitis is presented. This comprises 10% of all parotidectomies performed by one surgeon over the 5-year period between 1987 and 1991. In 16 patients, symptoms were relieved by surgery. The extent of surgery was guided by the clinical findings. In this series, near total and superficial parotidectomy were equally efficacious and no patient suffered permanent facial nerve dysfunction. Surgery is a safe and effective treatment for parotitis.

Herpes zoster oticus: treatment with intravenous acyclovir.

Herpes zoster oticus generally has a poor prognosis, leaving many patients with permanent facial nerve dysfunction. This preliminary report describes results in seven patients treated for zoster; all were given intravenous acyclovir. Patients were infused with 10 mg/kg every 8 hours over a 7-day hospitalization period. Five of the seven patients showed some return of facial function at the time of discharge. At follow-up, 4 patients had achieved a House grade I result, 1 patient a grade II, and 2 patients a grade III. Reasons for the differences in final results are discussed, along with a recommended regimen for treatment.