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Table of Contents
ORIGINAL ARTICLE
Year : 2010  |  Volume : 12  |  Issue : 2  |  Page : 41-48

Management of parotid tumours: a 17- year experience at tertiary institutions


1 Department of surgery, King Abdulaziz University Hospital and King Abdulaziz Hospital & Oncology Centre, Jeddah, Saudi Arabia
2 Department of Otorhinolaryngology – Head & Neck Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Date of Web Publication2-Jan-2020

Correspondence Address:
FRCS,FACS Faisal M H Al-Mashat
P. O. Box 143, Jeddah 21411
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274631

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  Abstract 


Objective: The aim of this study was to evaluate our personal experience (surgical oncologist and ENT surgeon) of parotid surgery for various parotid pathologies and to compare our results with other centres.
Methods: A 17-year retrospective review of 130 parotidectomies for benign and malignant diseases, collecting and analysing data about presentation, investigations, surgical treatment, postoperative facial nerve function, Frey’s syndrome and other surgical complications and follow-up.
Results: All patients presented with parotid swelling, unilateral or bilateral. Few patients had pain and preoperative facial palsy.
There were 66 males and 64 females . Their median age was 46.5 years , average duration of symptoms 48 months and mean size of swelling ± SD was 4.4±1.4 cm. Bilateral swellings were observed in 8 patients (6.2%). The investigations done included : fine needle spiration FNA), ultrasound (US), computed tomography (CT), magnetic resonance imaging MRI), magnetic resonance angiography (MRA), isotope scan and angiography. The surgical treatment was superficial parotidectomy for 116 patients, total parotidectomy for 14 patients and total parotidectomy with neck dissection for 12 patients. The traditional antegrade approach was used in 121 patients (93.1%). The overall rate of complications was 43.1%. The most common post operative complication was facial nerve paralysis which was noted in 38 patients (29.2%). The paralysis was temporary in 27 patients (73.0%) and permanent in 10 patients (27.0%). Frey’s syndrome was seen in 19 patients (14.6%). The final histopathology was 73.1% benign and 26.9% malignant. The median follow-up was 52 weeks. Operative mortality was zero.
Conclusion: Parotid surgery is a delicate surgical intervention requiring a sound anatomical knowledge and surgical expertise to provide a safe and oncologically acceptable outcome. Our results are in parallel with other reported studies.

Keywords: Parotid tumours, Parotid surgery, facial paralysis frey’s syndrome.


How to cite this article:
H Al-Mashat FM, Al Muhayawi SM. Management of parotid tumours: a 17- year experience at tertiary institutions. Saudi J Otorhinolaryngol Head Neck Surg 2010;12:41-8

How to cite this URL:
H Al-Mashat FM, Al Muhayawi SM. Management of parotid tumours: a 17- year experience at tertiary institutions. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2010 [cited 2022 Nov 30];12:41-8. Available from: https://www.sjohns.org/text.asp?2010/12/2/41/274631




  Introduction Top


The parotid gland is the largest of the major salivary glands. The gland is divided arbitrarily into the larger superficial (80%) and smaller deep (20%) lobes by the facial nerve (cranial nerve VII). Neoplasms of the parotid gland include a heterogeneous group of histotypes with markedly different biological characteristics, behaviour, and evolution, therefore requiring different forms of treatment. Approximately; 75% of parotid masses are neoplastic and the remaining 25% are non-neoplastic. The vast majority of parotid neoplasms are benign (80%) and only 20% are malignant [1]. Pleomorphic adenoma (mixed tumour) and Warthin’s tumour (papillary cystadenoma lymphomatosum) are the most common benign tumours, while mucoepider- moid carcinoma and adenoid cystic carcinoma constitute the bulk of the malignant neoplasms of the parotid gland. The usual presentation is asymptomatic, painless mass [1],[2]. FNA may be of value. CT and MRI are the diagnostic investigations of choice. Superficial parotidectomy is indicated for benign tumours, while total parotidectomy with safe margins is the operation of choice for malignant tumours. The most serious complications of parotid surgery are damage to the facial nerve and development of Frey’s syndrome.


  Methods Top


This is a retrospective study evaluating the personal experience of two surgeons (surgical oncologist and ENT surgeon). From December 1992 to February 2009,138 patients with parotid swellings presented at King Abdulaziz University Hospital, and two major affiliated hospitals in Jeddah, Saudi Arabia, were studied. Eight patients have been excluded because they had advanced malignancy precluding surgery. The remaining 130 patients represent the core of this study. The data was collected from patient’s medical records using the ICD-9. The parameters gathered for analysis were, age, gender, symptoms and signs, duration of symptoms, size of tumour, types of surgery, histopathol- ogy of resected swellings, complications, adjuvant therapy and duration of follow-up. Patients who were unable to attend the outpatient clinic, because they live far away from our centres, were contacted and requested to mention any complications related to their previous parotid surgery. Patients underwent superficial or total parotidectomy, with or without facial nerve grafting or lymphadenectomy. None of the patients underwent limited excision. All patients had modified Blair incisions, except in patients who had preoperative biopsy, in which the scar was included in the incision. The main trunk of the facial nerve and the various branches were identified and preserved in all patients. Nerve stimulator was used in most of the cases to test facial nerve integrity. The data were entered into SPSS software and analysis of various parameters was carried out by a biostatistician.


  Results Top


There was almost equal percentage of both genders. There were 66 males (50.8%) and 64 females (49.2%). Their ages ranged from 15 years to 68 years (median, 46.5 years). The median age was 41 years for benign tumours and 53 years for malignant tumours. This age difference is statistically significant (P<0.05). All patients presented with characteristic parotid swellings elevating ear lobes [Figure 1]. The swellings were unilateral in 122 patients (93.8%) and bilateral in 8 patients (6.2%). All bilateral swellings were noted in patients with benign parotid diseases. Associated pain was noted in 26 patients (20.0%) who had chronic parotiditis and adenoid cystic carcinoma. The average duration of symptoms was 48 months (range 3-360 months). The short duration of symptoms was noted in patients with Warthin’s tumour and Acinic cell carcinoma. The size of swellings ranged from 2 cm to 20 cm (mean ±SD, 4.4±1.4 cm). Fifteen patients (11.5%) underwent open parotid biopsy at other institutions. Preoperative investigations included FNA (n=20), US (n=75), CT (n=74),MRI (n=11), and isotope scan (n=3). One patient with parotid haemangioma had MRA, and carotid angiography. There were 95 (73.1%) benign pathology and 35 (26.9%) malignant tumours [Table 1] and [Table 2]. All patients underwent parotidectomies: 116 superficial (89.2%) and 14 total (10.8%) [Figure 2]. The traditional antegrade dissection was carried out for 121 patients (93.1%) and 9 patients (6.9%) had retrograde approach. Nerve graft was done for 6 patients (4.6%) and the gap was grafted using the great auricular or the sural nerves. Lymphadenectomy was carried out for 15 patients (11.5%) with malignant neoplasms. Seven patients (5.4%) had flaps; sternocledomastoid or superficial musculeo apponeurotic system (SMAS) flaps. Post operative complications were noted in 56 patients (43.1%). Facial nerve paralysis was documented in 38 patients (29.2%) and it was the commonest post operative complication. It was temporary in 28 patients and permanent in 10 patients. Permanent paralysis was documented if paralysis persists for more than 6 months. The temporary facial nerve paralysis was noted in all patients with benign tumours (n=22) and the permanent paralysis occurred in all patients with malignant tumours (n=10). At the same time, it was found that the majority of permanent post operative facial palsy (80%) occurred among patients who had been subjected to total Parotidectomy, while the majority of temporary post operative facial palsy (85.7%) occurred in s Parotidectomy, and these differences are statistically significant (P<0.01). The permanent paralysis was seen in patients with malignancy and those who had total parotidectomy. Fifty percent of patients with temporary facial nerve paralysis recovered within 8 weeks. The marginal mandibular branch was mainly involved (63.2%) and other branches were to a lesser extent affected [Figure 4]. Nineteen patients (14.6%) developed Frey’s syndrome and all patients thought that sweating in the parotid region after eating is a normal situation. Direct questioning during follow-up revealed that 14 patients developed it soon after surgery, while in 5 patients it was detected few months after surgery. It was symptomatic in 9 patients (47.4%). Numbness of ear lobe occurred in 30 patients (23.1%). Other complications included seroma, sialocele, flap necrosis and first bite syndrome. Hospital stay was variable and averaged 3 day in 65% of patients. There were no recurrences of pleomorphic adenoma. One patient with low – grade mucoepidermoid carcinoma developed recurrence (2.5%) 8 months after surgery and required chemotherapy. Postoperative radiotherapy and chemotherapy was given to 29 patients (22.3%) and 4 patients (3.1%), respectively. Two patients with low-grade mucoepider- moid and acinic cell carcinoma died 8 and 10 months after treatment , respectively. The operative mortality was zero. The histopathological features of the most common pathologies encountered in this study are shown in [Figure 5] [Figure 3]a & [Figure 3]b.
Figure 1: Pleomorphic adenoma.

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Table 1: Subtypes of benign tumors arranged in descending order (n=95).

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Table 2: Subtypes of malignant tumors arranged in descending order (n=35).

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Figure 2: the trunkof facial nerve and its branches after superficial parotidectomy.

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Figure 3:

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Figure 4: Occurrence of post operative facial palsy and the affected branches.

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  Discussion Top


Most salivary gland tumours (80%) occur in the parotid gland. The superficial lobe is affected in 90% of cases. Benign tumours account for 75% and malignant tumours for 25% of cases [3]. The most common tumour affecting the parotid gland in adults is pleomorphic adenoma (80%) and in children is haemangioma [3],[4],[5]. Bilateral neoplasms occur in 2.4% of patients [6]. Pleomorphic adenoma of the parotid provides a therapeutic dilemma. It is a slowly growing, lobular, and not well encapsulated tumour, composed of epithelial and myoepithelial cells arranged in various morphological patterns. Thinning or absence of the pseudocapsule and the presence of fingerlike projections of the tumour have been observed in all histologic subtypes of pleomorphic adenoma, in particular the myxoid type [7]. While this tumor is benign, recurrence can occur up to 30 years post-treatment Many hypotheses for recurrences of parotid gland pleomorphic adenoma have been put forward, including cell biological and genetic factors, tumour spillage, incomplete excision, and violation of the pseudocapsule of the tumour are considered the only proven reasons contributing to recurrent disease (8.9.10) . This is why the abandonment of enucleation techniques in favour of more extended surgical procedures, which require the tumour to be excised with the surrounding normal tissue and the facial nerve to be identified and preserved, have dramatically reduced the recurrence rate of pleomorphic adenomas of the parotid gland from 20-45% to less than 4% in the last decades [11],[12],[13]. the risk of malignant degeneration has been established. Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex- pleomorphic adenoma occurring most frequently as adenocarcinoma. Warthin’s tumour is the second most common benign neoplasm of the parotid gland (5%) [14]. This tumour occurs most commonly in males as compared to females during the 6th and 7th decades of life. Bilaterality and multicentricity occur in 10% of Warthin’s tumours. It is extremely rare for Warthin’s tumours to undergo malignant transformation (0.3%) [14]. Malignant parotid tumours are uncommon and present a significant management challenge. Mucoepidermoid carcinoma is the most common, and accounts for 30% of parotid malignancies [15],[16]. High-grade tumours behave like a squamous cell carcinoma; low-grade tumours often behave similar to a benign lesion [17]. It is characterized by Limited local invasiveness and low metastatic potential, most likely regional nodal basins rather than to distant locations. On the other hand, adenoid cystic carcinoma is characterized by its unpredictable behaviour, an affinity for growth along perineural planes, and metastasis most frequently to lungs. These tumours require aggressive resection, because clear margins do not necessarily indicate tumour eradication.

CT and MRI are the two imaging modalities of value for evaluation parotid tumours [18]. Both have sensitivities approaching 100%. CT provides better detail of the surrounding tissues particularly parapharyngeal space, whereas MRI demonstrates the mass in greater contrast than a CT scan. MRI is the preferred modality for evaluating a painless parotid mass. CT is well suited for evaluating recurrent, tender parotid mass that can be inflammatory.

FNA is a valuable diagnostic test, with an overall accuracy greater than 96% in experienced hands. It may not distinguish benign from malignant epithelial lesions because malignancy of parotid epithelial cells is related to the behavior of the tumour cells rather than cellular architecture, which may be rather normal even in malignancy. It can change the clinical approach in up to 35% of patients. Many surgeons do not routinely perform FNA before proceeding with surgery. However, only a positive diagnosis should be accepted. Incisional biopsy should not be performed because it has a high rate of local recurrence and places the facial nerve at risk for injury from inadequate visualization. The standard biopsy is a superficial parotidectomy with preservation of the facial nerve. Frozen section has greater than 93% accuracy, but its use is controversial. Surgery is the primary modality of treatment for parotid gland tumours. Superficial parotidectomy is the treatment of choice for most benign tumours in the superficial lobe. Local excision of Warthin’s tumours had the following advantages over superficial parotidectomy: shorter operating time, less risk of facial nerve damage, less facial deformity, lower incidence o f Frey’s syndrome, and better preservation of the function of the parotid gland [19]. Superficial parotidectomy is an appropriate procedure for malignancies confined to the superficial lobe, low grade, less than 4 cm in greatest diameter, no local invasion, and those without evidence of regional nodal involvement. Total parotidectomy is indicated for malignant tumours not fulfilling the above criteria or for deep lobe tumours. Neck dissection should be performed for tumours >4 cm in greatest diameter, high-grade, local invasion, recurrence, regional lymph nodes metastasis, and deep lobe tumours.

Radiation therapy is considered the cornerstone of adjuvant therapy, and is usually indicated for all parotid malignancies with the exception of small low-grade tumours with no evidence of local invasion or nodal/distant spread. Post operative radiotherapy criteria include: tumours >4 cm in greatest diameter, high grade, local invasion, lymphatic invasion, neural invasion, vascular invasion, tumour very close to a nerve that was spared, tumours originating in or extending to the deep lobe, recurrent tumours, positive margins, and regional lymph node involvement.

No chemotherapy has been proven effective as single modality therapy. Presently, immunotherapy is in the clinical trial phase. A recent study demonstrated that epidermal growth factor receptor (EGFR) is expressed strongly in the cell membranes of parotid mucoepidermoid carcinomas and of the lymph node metastases [20]. EGFR-targeting agents have potential to be used for therapy.

Precise attention to surgical landmarks and technique will reduce complications. The surgeon’s expertise had no influence on the incidence of complications [21]. Facial nerve injury is a major concern following parotidectomy and every effort must be practiced to identify and preserve the main trunk and its branches. The surgical approach to the facial nerve should be as conservative as possible, reserving radicality for the most advanced and aggressive cases compromising the adjacent vital structures. The motor facial nerve function is classified according to the House-Brackmann grading scale. The reported overall incidence of facial paralysis ranges from 10.8% to 53% (temporary 15 – 65.2% and permanent 2.1 – 15% [6],[22],[23]. Most of the deficits were partial [24]. The most common dysfunction was paresis in a single nerve branch (48.2%), in particular, the marginal mandibular branch [24],[25],[26]. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected [27]. There are many factors related to the development of postoperative facial paralysis. These include: extent of surgery, histopathological findings, sectioning of facial nerve branches, tumour size, close contact of tumour with facial nerve, duration of operation, Parotid duct ligation, deep tumours, previous parotid surgery, previous neck radiotherapy, and inflammatory conditions [24],[25],[26],[28],[29]. Total parotidectomy was associated with a significantly higher incidence of facial nerve dysfunction (60.5%) than superficial parotidectomy (18.2%) [23],[25],[28]. Recurrence of benign tumours is also a risk factor for the increased incidence of facial nerve paralysis (53% : temporary 38 % and 15 % permanent) [22]. Permanent paralysis was noted in 30% of patients with malignant tumours following parotidectomy [30]. A prospective topographical analysis of the facial nerve indicated that facial nerve paresis after parotidectomy is associated with the length of nerve dissection. The greater the length of facial nerve dissected, the higher the chance of facial nerve paresis [27]. No statistically significant difference could be found between anterograde and retrograde approach in terms of facial nerve injury [1]. The intraoperative use of facial nerve stimulation did not influence the likelihood of facial paresis [29]. There was no difference in the incidence of postoperative facial nerve paresis or paralysis between the stimulated and non-stimulated patients. Routine use of a stimulator is not necessary during parotid surgery because its use does not prevent or promote facial nerve injury [31]. The intraoperative use of nerve-integrity monitors has been advocated to reduce the incidence of facial nerve paralysis. Dulguerov found that facial nerve monitoring during parotidectomy is very helpful, but the lack of a control group precludes definitive conclusions on the role of electromyograph-based facial nerve monitoring in routine parotidectomy [24]. Similarly, Witt found that the incidence of transient facial nerve paralysis following lateral parotidectomy with and without nerve-integrity monitoring was 20% and 15%, respectively, and concluded that nerve monitoring is optional [32]. Frey’s syndrome (gustatory sweating) is one of the potential sequelae of parotidectomy. It results from aberrant regeneration of auriculotemporal nerve fibers (parasympathetic fibers) to sweat glands of overlying skin in the parotid region. Therefore, when patient eats, drinks, smells, tastes or even thinks of food, sweating and erythema occurs over parotid region. Gustatory sweating is a common complication of parotid surgery[33]. However, it is usually underestimated. The main reason for this is because it is asymptomatic in majority of patients and can be documented on direct questioning of patients. Minor’s starch iodine test proved that 85% to 96% of the patients who did not notice Frey’s syndrome after surgery actually had a subclinical manifestation[33],[34]. Only 6% of patients experience severe symptoms [34]. Almost all patients following superficial parotidectomy will develop the syndrome [35]. The reported incidence ranges from 4% to 53% [24],[36]. The syndrome usually appears soon after parotidectomy. Delayed onset appearing 8.5 – 14 years after parotidectomy has been reported [34],[37]. No significant differences were found between patients treated with partial vs. total parotidectomy or between patients treated with or without adjuvant radiotherapy [38]). Preventive measures are available to reduce the incidence of Frey’s syndrome. This is achieved by inserting barriers between the overlying skin flap and the parotid bed. The sternocleidomastoid muscle flap, and SMAS are efficient methods [39],[40]. On the contrary, the incidence was not altered by the use of a sternocleidomastoid muscle flap or other implantation material [36]. The interposition of ALLoDerm, an acellularhuman dermal matrix graft has also been found to reduce the incidence of this syndrome [41]. Treatment is required in only 6% of patients [42]. Intracutaneous injections of botulinum toxin A (Botox) are highly effective and safe, and considered as the treatment of choice for Frey’s syndrome [35],[43],[44]. Sensory disturbance due to excision of the great auricular nerve in patients who have undergone parotidectomy sometimes causes discomfort to the patients. Yokoshima et al noted that preservation of the posterior branch of the great auricular nerve during parotidectomy is valuable in order to reduce the postoperative sensory disturbance of the pinna. It further helps to improve the quality of life [45]. Overall, parotidectomy for malignant and benign disease does not seem to severely affect quality of life [46].


  Conclusion Top


Parotid surgery is a delicate surgical intervention requiring a sound anatomical knowledge and surgical expertise to provide a safe and oncologically acceptable outcome in terms of complications and quality of life. Familiarity with the common variations in facial nerve anatomy is an absolute necessity for the operating surgeon. Our results are in parallel with other reported studies.



 
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